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APPLICATION FOR PER, SAN JOAQUiN LOCAL HEALTH ' 1' RICT 1601 E. HAZELTON AVE., 54, 1 N, CO('T U 11983 PERMIT NO. 7K� Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DAT ED CAQUIN LOCAL ! (Complete in Triplicate) HEALTH 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 Df the San Joaquin Local Health District. Jab Address _5 76 Gv, ip�js� i! Owner's Name Address 6- 62,ef Phone Contractor's Name License No..&., Phone 74r_C. 6' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION- SYSTEM REPAIR l-? OTHER �i w 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 I 1 industrial T U,Open.Bottom.,.Y_y [] Manteca, Dia.—of-WelLExcavation.�.-_ Domestic/Private Gravel Pack Tracy Dia, of Well Casing 1-1 Public F-1 Other Delta Type of Casing E] Irrigation Approx. L] Eastern I� Depth Specifications Cathodic Protection p Depth of Grout Seal Geophysical U Type of Grout Other tt!{{{ - Surface Seal Ins�tlalled by Repair Work Done K Type of Pump k.P. State Work Done Well Destruction U Well Diameter f7 Sealing Material (top 50') f Depth Filler Material (Below 50') Q TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is 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 U Type/Mfg Capacity 0 Compartments i PKG. TREATMENT PLT. U Type/Mfg Capacity "—Method of Disposal � SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of 7-fines --. — .•Total-length/size--- FILTER BED Distance to nearest: Well Foundation Property Line ti SEEPAGE PITS Depth Size Number I SUMPS Distance to nearest: Well ',. Foundation Property Line DISPOSAL PONDS 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 ofithe 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 workmans compensation laws of California." w 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 applicant ust 11 for al required i spections.' Complete awing o_n re/verse side. 1 Signed X Litle: %, Date:/Q FU—.DEPARTMENT USE ONLY # Application Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by = s � aus� Date y1—� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., ICA 95201 FEE SASE AMOUNT DUE RMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ! { INFO $_3 �3-1 15 £H 13-24 REV. 10/82 .10/82 500 14-26