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APPLICATION'FOR PERMIT v 4 SAN JOAQUIN LOCAL HEALTH DISTR J 1601 E. HAZELTON AVE.,+�STOCKTON Telephone (209) 466-6781 (� 190'___ MIT N0. r PERMIT EXPIRES 1"Y.EAR FROM DATE ISSUED J�� y �� _ GATE ISSUED~` (Complete .in Triplicate) Application is'hereby made to the San Joaquin Local Health District fora peAN ,OAQ UI N LOCAL' i. described. This application is made in compliance with San Joaquin County Ordin ce o. 549 for secD1STwage or No. 1862 for well/ um f and the Rules and Regulati"ons of the San Joaquin .Local Health District, for sewge tall the work herein Job Address 1001 West Center Street p p Owner's Name CITY OF NTAMMCA Subdivision Name ' Address 1Q01 ' C Contractor's Name �� Phone �jj DRILLING 00M License No. 434218 239-9511Phone L201119 602-7932 TYPE OF WELL/PUMA WORK: NEW WELL — 3 ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION (❑ SYSTEM REPAIR ❑ OTHER DISTANCE TD NEAREST: SEPTIC TANK TEST ISLE �.�^_ SEWER LINES DISPOSAL FLD,FOUNDATION AGRICULTURE WELL PROP, LINE WELL PITS/SUMPS INTENDEp USE 12E OTHER OF WELL PROBLEM AREA I J.Industrial �--�_ CONSTRUCTION SPECIFICATIONS Open Bottom � �Manteca Domestic/Private Dia. of Well Excavation ❑Gravel Pack Trac 4T OCH 4 - ❑ Public ❑ y Dia. of Well Casing [� Other`j'EST' HDL@ Del to Irrigation A r Type of Casing 0 ) [7j Cathodic Protection _UD - Depth EJ Eastern Specifications ❑ Geophysical Depth of Grout Seal Other TEST BDLE Type of Grout Repair Work Done DiType of Pump H P Surface Seal Installed by ❑ State Work Dane Well Destruction ` Well Diameter Sealing Material (top 501) / Depth Filler Material (Below 50') "^ TYPE OF SEPTIC WORK: NEW IN ❑ REPATR/,ADDITION ❑ (No septic tank or seepage it Installation will serve: Residence _ Commercial Other p permitted if public sewer is available within 200 feet.) Number of livingunits: Number of bedrooms Lot size � Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEM Capacity Method of Disposal , DESTRUCTION C1 Distance to nearest: Well Foundation _ Property Line LEACHING CINE" ` ❑ No." & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS De th ❑_ wp Size Number SUMPS : ..-. " . ❑� Distance to nearest: WellFoundation DISPOSAL PONDS Property Line x , D E 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D#strict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman$ compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following "I certify that in the performance of the work for which this permit is issued, I sh 11 employ persons subject to workman's compensation laws of California." The applicant muss al all a Jr inspections, Complete drawing on revers e. side. Signed Title: DIRE= OF PUBLIC Date: �.2-,�i1 0 EPARTMENT U ONLY Application Accepted by Area _ `—'� ❑ Stk 466-6781 Additional Co.ments: Pit or Grout Inspection ❑ Lodi 369-3621 Date Iti- Manteca 823-7104 Final Inspection by � Date ��---6Q�� j�`- Applicant - Return al s 't : E viro mental e I h P rmit/Servi e 1601 E. Haz lien qv Q, Be Tracy200835-6385 A 95201 1 r O �� /l I FEE BASE AMOUNT DUE AMOUNT REMITTED Gi INFO RECEIVED BY DAT PERMIT NO. �Xp-T Dib 1 tEH 13-24 REV. 10/82 11 " "`� I4-26 10182 500