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APPLICATION FOR PER'117 SAN JOAQUiN LOCAL HEALTH 71ST i 1601 E. HAZELTON AVE., STOCKTD IIRMIT NO.12 Telephone (209) 466-b78�P 7 qh DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in triplicate) StIN ,v^# LOCAL Icy , Application is hereby made to-the San Joaquin Local Health District for a per ''! t icu'o tr�bC ri Y ns tall the work herein described. This application is made in compliance with San Joaquin County Ordinance and the Rules ann�dyy Reguula�t''ons of the San Joaquin Local Health District. No, 549 for sewage or No. 1852 for well/pump Job Address !. �i t/ bdivision Name Owner's Name Address V Phone Contractor's Name C�00 No. �— Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS b Industrial U Open Bottom Manteca Dia. of Well Excavation - 9 1 [_J Domestic/Private Gravel Pack Tracy Dia, of Well Casing Public _ U Other Delta Irrigation Type of Casing L—I 9 Approx. Eastern Specifications Cathodic Protection Depth p Geophysical Depth of Grout Seal Ll Other 7'Y� � �p®— Type of Grout - Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. E State Work Done 994W43d �- Well Destruction ❑ Well Diameter Sealing Material (top 50') -.� Depth Filler Material (Below SO') TYPE OF SEPTIC WORK: NEW INSTALLATION EJ1 REPAIR/ADDITION j) (No septic tank or seepage pit permitted if public sewer is G available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: , Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total- length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS t—I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 fallowing: "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." t The applicant u . cal for all required inspections. Complete drawing on reverse side. Signed X Title: _ , � � Date: F EPARTM T USE ONLY Application Accepted by Area _ �. Stk 466-6781 Additional Comments: TT Lodi 369-3621 Pit or Grout Inspection by Date srlanteca 823-7104 Final Inspection by Date TE-7 -2v0 Tracy 835-6385 Applicant - Return all copie o: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 11 FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. d r INFO p,w- E S a ta �83 $3- 1002 7 � EH 13-24 REV. 10/$2C�� 3 jIs� 10/82 500 14-26 "l