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114 APPLICATION FOR PERMIT D� � � SPM JOAQLi" LOCAL HEALTH JiSTRI SEP 141933 SEP1601 E, HAZELTON AVE., STOCKTON, CA J PERPIIT NO. Telephone (209) 466-6781 � N 3()n'QUar3 LOCAL PERMIT EXPIRES I YEAR FROM DATE ISSUE . ��` Q1,,jr4 j_0CADATE ISSUED �$ [.. INSTRlG-f (Complete in Triplicate) H�.�1L H DISTRICT 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, CA Job Address 6956 E. VeritassManteca Subdivision Name i Owner's Name Rosalie Souza. Address same Phone 239-1621 Contractor's Name Larsen PumpS Le No 276660 Phone 529-2020 TYPE OF WELL/PUMP WORK: -NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION -1 SYSTEM REPAIR, 9OTHER � a ❑ DISTANCE TO NEAREST: SEPTIC TANK �t1r.� SEWER LINE ,3 _ DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL-I OTHER WELL '7,57 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM'AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ® Manteca Dia, of Well Excavation �gf Domestic/Private ❑ Gravel Pack ❑ Tracy 1 Dia. of Well Casirg 67 �] Public ❑ Other ❑ Delta S' Type of Casing Irrigation 106 t Approx. Eastern Specifications Depth Cathodic Protection ❑ - Depth of Grout Seal ❑ Geophysical. Type of Grout ❑Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done S Well Destruction ❑ Well Diameter Sealing Material (top 501) ` Depth Filler Material (Below 50') y� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is v available within 200 feet.) Installation will serve: Residence _ Commercial Other i Number of living units: Number of bedrooms Lot size �l Character of soil to a depth of 3 feet: Water table dept h. SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal G SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION f7 (" LEACHING LINE L No. & Length of lines Total length/size f` FILTER BED ❑ Distance to nearest: Well Foundation Property Line 5EEPAGL PITS [j Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �1 I 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 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." 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 applic nt m st call for all required inspections. Complete drawing on reverse side. Signed X Title: Serviceman Date: -§/31/83 F19 ARTMENT U ONLY Gr ❑ Stk 466-6781 Application Accepted by Area _____ Lodi 369-3621 Additional Comments: ❑ Pit or Grout Inspection by Date Manteca 623-7104 Firal Inspection by Date U 2 7 L Tracy 835-6385 Applicant - Return all copies to: it nmental 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 �y S, N S, o o v� e:�/%LVT-a 'Era 1.=.is 10/82 500 EH 13-24 REV. 10/82 14-26