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APPLICATION FOR PERMIT i, SAN JOAQUIN LOCAL HEALTH DISTRIC 1601 E. HAZELTON AVE., STOCKTON, I IT NO. gZ-4,']Q Tel ephone,(209) 466-6781 NODI 2 91982 DATE ISSUED , Z PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) sl�.�`F��q� �gr'� j LOCAL Application is hereby made to the San Joaquin Local Health District fora perm it1t L�Ttr'UJD"R10%tall the workherein described. This application is grade in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump 1 and the Rules and Regulations of.the San Joaquin Local Health�D' trict. - Job Address .3.3 �L S. p 't7EG.t sr. �7`7�,,bdivision Name Owner's Name A45e.EZ Address , /K E ST 5 PhoneL fir/ Contractor's Name License No. L Phone Sib 3�3 9 7f TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTtALLATION [] SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ry. Open._Bo.tt% aManteca_. __ �— � � _ _ ia. of1e117 1 Domestic/Private [J Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public [J Other Delta F-1 IrrigationType of Casing Approx. [j Eastern ❑Cathodic Protection ;,Depth Specifications Geophysical Depth of Grout Seal LJ Other I Type of Grout WRepair Work Done EJ- Surface Seal Installed by Type of Pump H.P. State Work Dyne Well Destruction Lf Well Diameter,t' Sealing'Materiai (top 501) Depth f Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of-3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distanceto nearest: Well Foundation Property Line . LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance' o nearest: Well Foundation 7 t _WA AM, Property Line SEEPAGE PITS Depth 2��C — Size _ 3 `� Number —T_--C—J-.,D.i•stance�,to nearest:;--Well Foundation -.... erty Lrrre� DISPOSAL PONDS ❑ I hereby certify that I have prepared this application€and that the work will be done in accordance with sin Joaquin county ordinances, state laws, and rules and regulations of tl�e San Joaquin Local Health District. Home owner or 1 icensed agent's signature certifies the foul owing.:,,�YiRcerti.f-y,-thatin.rthe-.perfo-r coma ee 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 shall employ persons subject to workman's compensation laws of California." The applicant must call for all required ins p tions. Complete drawing on reverse side, Signed X i Title: Date: I Application Accepted by FO MENT USE ONLYArea Stk 466-6781 Additional Comments: 1 Lodi 369-3621, Pit or Grout inspection Date Q Manteca 823-7104 Final Inspection by Date EJ Tracy 835-6385 Applicant - Return all copi Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO' EH 13-24 . REV. 10/82 F 14-26 10/82 500