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w APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZ£LTON AVE., STOCKTCN, CA PERMIT NO. Y,3 Telephone (209) 466-6781 DATE ISSUED 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 Count Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local He tl� f l Job Address ElQIF ub ivision a Owner's Name 124 FOCI&O — Address Phone Contractor's Name =�uLE License No. ��S,57 Phone ,3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WEtL,REPLACEMENT ❑ DESTRUCTION ❑ ^"� a PUMP INSTALLATION SYSTEM REPAIR - - -�-- - ❑ ....❑ OTHER •❑ .y» DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom , ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing r ❑ Public ❑ Other ❑ Delta irrigation Type of Casing V 9 Approx. ❑ Eastern .� ❑Cathodic Protection Depth Specifications Depth of Grout Seal x Geophysical ❑ ,. Type of Grout ❑Other Surface Seal Installed by Repair Work Done " Type of Pump H.P. State Work Done c�- Well Destruction ❑ Well Diameter Sealing_Material (top 50') _ (�s Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other P I Number of living units: I Number of bedrooms �� Lot size Character of soil to a depth of 3 feet: <42n Water table depth , SEPTIC TANK ❑ 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 amu--- -- Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ +, I hereby certify that�l have prepared this application and that the work will be done in accordance with San Joaquincounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies t;he'followingi "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workmanis 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." � w The applicant must cal for ll req .redminspections. Complete drawing on reverse side. Signed X_ ry Title: w� _ Date: "r1 FOR DEPARTMENT USE ONLY Application Accepted by � � Area 0 - ❑ Stk 466-6781- Additional Comments: ❑ .Lodi 369-3621 Pit or Grout'Inspection by Date Manteca 823-7104 » Final Inspection'byrt Date �.'Z�� 01, L7Tracy 835-fi385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0,Box.2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT, REMITTED RECEIVED BY DATE PERMIT NO. INFO " r. 1�I`4 �3 d2� -13- 72 EH 13-24 REV. 10/82 1v 4t',' 2 ( ,f//S d 10/82 500 14-26