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I APPLICATION FOR PERMIT SAN JOAQbiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., ETOCKTON, CA PERMIT N0. _ Telephone (209) 466-5781 n; GATE ISSUED ``f - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Distri t. Job Address 12 Z 2AVf ,E. VNE 57- � d ion Name Owner's Name DAYtD WA7=C#?A14Z Address j Phone 4/r.444r jlL/ Contractor's Name �` � {��dD License No, Phone 446"- _:Z/ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP'INSTALLATION ❑—SYSTEM'REPAIR U "*""a""' -OTHER' U f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP05AL FLO. PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ !Open Bottom � Manteca Dia. of Well I Excavation ? ❑ Domestic/Private Gravel Pack 0 Tracy Dia. of We11,Casing 17 Public Other ® Delta Irrigation Type of Casing Approx. [] Eastern' Specifications , ✓ [ Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Other Type of Grout71 Surface Seal Installed by 4 s Repair Work Done ❑ Type of Pump H.P. State Work Done f I s Well Destruction ❑ Well-"ami et Sealing Material (top 501) _ I Depthu 1 Filler Material (Below 50'} TYPE OF-SEPTIC::WORK: NEW„_INSTALLATION L REPAIR/ADDITION [?"'(No septic tank�or seepage pit permitted if public sewer is available within 200 feet.) cu Installation will serve: Residence ►� Commercial Other + _• Number'of living units:" / ,+ Number of bedrooms �� Lot size �n Character of soil to a depth of 3,feet:- g2 LA y Water table depth �V(�, SEPTIC TANK Ei� F Type/Mfg (�RfP-�eT2c __R Capacity /Ztl0 i No. Compartments V ' PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: well Foundation DESTRUCTION ❑ �O +Property Line LEACHING LINE ❑ No. & Len t-y�f lines Total length/size'I � � FILTER BED st n dlearest: Well Foundation Property Line SEEPAGE PITS _j I Depth—.--J Size Number SUMPS ❑I Distance to nearest:1 well I Foundation property Line DISPOSAL PONDS ED } l I hereby certify that I have ,prepared thlsCapFplication andlthat 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 licensedagent's signature{certifies the following: "I certify that in the performance of the work for which this f 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 certifiestf:e followTng: "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 1 required ins p tions. Complete drawing on reverse side. i _ p3 Signed X i Title: _¢ Date: d d DEP MENT USEfONLY Application Accepted�y „ Area - Stk 466-6781_4711 Additional Comments: .Lodi 369-3621 Pit or Grout Inspection by Date LJ Manteca 823-7104 Final Inspection by '°” "Date ❑ Tracy 835-6385 i Applicant - Return all copies to: Envi ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 - k FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO / Y_3 83-1 Y EH 13-24 REV. 10/82 10182 5 0 - 14-26