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APPLICATION FOR PERM17 I SAN JOAQUiN LOCAL HEALTH Di STRICT ' 1601 E. HAZELTOTelephone AVE., 66-678 STOCKTGN, CA PERhiIT N0. 772 7eiephane (209) 46b-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED tt� 7� � (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 �`� 5'J 5«l/G�L.4zf? -�g�� Subdivision Name Owner's Name � /� �� Address / �,AJ ' Contractor's Name Phone License No, IntPhone`-�/�d�' TYPE OF WE WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER Fj DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE- y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE : TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U`Open Bottomm , Manteca �_ Dia, of Well Excavation Domestic/Private Gravel Pack Trac Y Dia. of Well Casing Public Ej-Other_ „ Q Delta F`1 Irrigation tastern - TY pe of Casirig� "^"+ Cathodic Protection Depth , -,,-I v Speci•fications ! z Tic ❑ Geophysical u,�. .i� so', f/\ Depth of Grout Seal U OtherTyP,e�of Grout ./ Surface Seal Installed by Repair Work Done ❑ Type of Pump H;P_ 21 ,-State Work Done f Well Destruction U Well Diameter Sealing Material (top°`501-)? U Depth Filler Materia;lJBelow 50') 3 TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR ,ADDITI( j� 'o' '- l_J / I {No septic tank or seepage pit permitted if public sewer;is�. - Installation will serve: Residence Commercial Other available within 200 feet.) , q Number of living units: Number of bedrooms F^ZT l~ } Lot size` 757SC �•ZS Character of soil to a depth of 3 feet; ��,�� ,'•<_ �r� Water table depth SEPTIC TANK Type/Mfg ? G, " = 2/ 1.5 , Capacity No. Compartments z� PKG, TREATMENT PLT. Type/Mfgf " G Capacity Method of Disposal SEWAGE SYSTEM ��---1 Distance to nearest:` WeII r �r'�Foundation - -Property Line, DESTRUCTION LEACHING LINE No. & Length of lines -- k/1Gc7 r Total length/size � FILTER BED Distance to nearest: Well `^- Foundation / Property Line j SEEPAGE PITS Depth -2--S-_ Size _ � Number -V SUMPS L—j Distance to nearest, Welt 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 A- 4]6h sed agent's signature certifies the following: "I certify that in the performance of the work for which this permishall not employ any person in such manner as to become subject to wvrkman� compensation laws of California." Confror sub-contracting s nature certifies the following: "I certify that in the performance of the work for which this d, ] shal employ` er ons su ect to work an'scompensation laws of California." The aT1 for 1 req r inspe ions Compl adr on reverse side. Signetle: Date: F PARTMENT USE ONLY Application Accepted by Area ( 1. t 4666781 Additional Comments: E] Lodi 369-3621 Pit or Grout Inspection b ' Date1 _ Manteca 823-7104 Final Inspection by Date /r�_.0 kn Lj Tracy 835-6385 Applicant - Return all copi Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F'FEE -BASE — "AMOUNT-'DUE'"- `'^ AMOUNT REMITTEDRECEIVED $Y - -- a^DATE -- - PERMIT-NO.NFO 1 I- EH 13-24 REV. 10/82 10/82 500 14-26 x