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APPLIC q ATION FOR PERI�Ir �M r '1,�1� SAN 30AQU i N LOCAL H "6"" 1�7 1 EALTH u 1601 E. HAZELTON AVE �T Telephone 209 X466-6781 'PERMIT NO p (. � , cA n�� 3 " PERMIT EXPIRES 1 YEAR FROM DATE � R FA� DATE ISSUED {Complete in Triplicate) '�' _ APPlication is hereby made to the Sar Joaquin Local Health District for a described. This application is made in compliance with San Joaquin Count `1� �� , and the Rules and is of Permit to construct r the San Joaquin Local Health District, y-Ordgnance No. and/or install the work herein Job Address 3 f f 549 for sewage or No, �. [ /� lgfiy-for well/pump a Owners Name - y1 � ! Subdivision Name Contractor's Name Address A ! i= License No, PhoneS� O TYPE OF WELL/PUMP IJORK: Phone N"iWELL WELL REPLACEMENT PUMP INSTALLATION (� SYSTEM REPAIR DESTRUCTION U , DISTANCE TO NEAREST: SEPTIC TANK -�� .O_ SEWER LINES OTHER E _ FOUNDATION l I---- Q DISPOSAL FLD. Q (j PROP. LINE #`} .�� AGRICULTURE WELL �-.- INTEN�.- �� OTHER WELL .__ TYPE WELL -PROBLEM AREA �— PITS/SUMPS I ) Industrial —�_ CONSTRUCTION-;SPECIFICATIONS. Domestic/Private ~ Open Bottom 0 Manteca Gravel Pack Dia, of Well Excavation fd j] Public Tracy 'Other Dia. of Well Casing ❑ Irrigation Delta Approx. [�[ Eastern Type of Casing� Cathodic Protection Depth Geophysical Specifications Depth of Grout Seal pQ I,I Other 04Type of Grout Repair Work Done ❑ Type of Pump Surface Seal Installed by Well Destruction U �— H.P. State Work Done Well Diameter 1 Sealing Material (top 50') Depth I Filler Material (Below 5o') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,4DDITION J (Ne septic tank or seepage Pit Permitted if public sewer is Installation will serve: Residence Commercial Other LJ Number of living units: Number of bedrooms available within 200 feet.) Character of soil to a depth of 3 feet: - - Lot size SEPTIC TANK Ej Type/Mfg 1 �—� dater table depth ' PKG. TREATMENT PLT.' T Capacity No. Compartments �t1 ❑ Type/Mfg # Capacity v SEWAGE SYSTEM Distance to:nearest: Yell Method of Disposal DESTRUCTION ❑ Foundation Property Line LEACHING LINE U No. & Lengthlof lines �~ — A FILTER BEDTotal length/size Distance to nearest: Well Foundation Property Line ,. .�--.SEEPAGE.PIT.S Depth; SUMPS _ - Size ,Number L-1 Distance to nearest: Well DISPOSAL PONDS Foundation Property Line 's CI I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county s F Homenowner�ortlicensed�agentand rslsignaes auregcertifiesulations otheh£ollowie San �gqu"i certifyin Local that District. the ricperformance of the work for alth permit is issued, I Shall not employ any, person in such manner as to become subject to workmant compensation laws of which California." Contractor's hiring or sub-contractin � " j this permit is issued, I shall employ g,signature certifies the following: "I certify that in the performance of the work for which p y persons subject to workman's compensation laws of California." The applican t ca f required inspections. Complete draw' Signed X �g on reverse side. Title: Application Accepted b DEP MENT ONLY Date: Additional Comments: I Area Q � Silk 466-6781 Pit or Grout In by / Lodi 359-3621 t Final Inspection by Date D Manteca 823-7104 ❑ Applicant Date Tracy 835-6385 Return all s- copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT N0. • a S 3 EH 13-24 REV. I0/82 14-26 i . 10/82 500