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• APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT / ( �/ 1601 E. HAZELTON AVE., $TOCKTON, CA PERMN0. d'� ( � 7 Telephone (209) 466-6781 /' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED f(� .r YI 43 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � Q .a�p; �/. �3udF _MSU division Name Owner's NameQ Address /� Phone ff 3)1!00 Contractor's Name A4v License No. Phone 4),ev—sowe TYPE OF WELL/PUMP WORK: NEW WELL [) - WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR U OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia, of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing ( n Public F-1 Other Delta U 1 Li 9 Approx. Eastern IrrigationType of Casipg � ❑Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done F—J Type of Pump H.P. State Work Dore Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) -TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer isJ d Installation will serve: Residenceavailable within 200 feet.) �— Commercial _ Other [ � Number of living units: 'ONSittber of bedrooms Lot size S 1J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg 00A_ �'� Capacity�6r&&I? No. Compartments iZ, d PKG, TREATMENT PLT, Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well —954 Foundation _ P 1 Property line DESTRUCTION LEACHING LINE U No. & Length of lines =20, Total length/size 10 FILTER BED ❑ Distance to nearest: Well Foundation Property Lire SEEPAGE PITS cF.-_ depth Size s Number SUMPS Distance to nearest: Well ,oundatiorProperty Line DISPOSAL PONDS L:;;— I hereby certify that I have prepared this application and that the work wiTl be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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." Cont;,ratjor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thisarmit is issued, I shall employ persons subject to workman's compensation laws of California." r Thepa pl - us a or all q i pecticns. Complete drawing on reverse side. Sign + Title: Date: P TMENT ONLY Application,Ac epted ` Area 3 E] Stk 466-6781 Additional Comments Lodi 369-3621 Pit or Grout Inspection by Date " Manteca 823-7104 Final Inspection by Date A) _ 3 /}/ /� Tracy 835-6385 Applicant - Return all copies t Environmental Health Permit/Services 1601 E. Hazelton Ave, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY " DATE PERMIT NO. INFO q- 3 - l� EH 13-24 REV. 10/82^ �Q �� f I 10/82 500 14-26 •