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APPLICATION FOh PERMIT SAN JCAQU'LN LOCAL HEALTH Tri 1601 E. HAZELTON AVE., ST OC KT A k%Jr, 2F+�.7v� PERMIT NO. ��- Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �{'i � LMAL DATE ISSUED (Complete in Triplicate) BEAL-[ S ��TR1CT 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 f the San Joaauin_Local Health District. Job Address gjQ li(J� ai/l,�i�.*_ Subdivision Name }� Owner's Name`], � iht ye�3i /ress �/ Q L[.I� . �. , Phone .1^�(I O.C.c+u..s./ E Contractor's ame _ License No. /re �?3�3 - Phone TYPE OF WE WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIDN ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U A IPPP DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �7 FOUNDATION AGRICULTUREWELL OTHER WELL PITS/SUMPS 4 INTENDED-USE TYRE OF WELL` - -PROBL-EM-AREA' S CONSTRUCTIONS-PEH-FIGATIDNS- - -- -`'- _ ❑ Industrial U Open Bottom ,❑ Manteca r Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public 1 ❑ Other ❑ Delta Type of Casing L, Irrigation _ Approx. Eastern i yti;. ;l`•.,` Specifications F-1Cathodic Protection_ w Depth -f- �- .----: Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by r��s � � Repair Work Done Type of Pump `�(�( H.P. / State Work Donee�c. t1 >�t� Well Destruction ❑ Well Diameter !—`-- Sealing Material �(top 50') ' a Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage, pit permitted if public sewer i-s L available within 200 feet.) Installation will serve: Residence ,r 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, ❑j Type/Mfg Capacity %. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg 'Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well F6undation Property Line DESTRUCTION LEACHING LINE U 1No. & Length of lines Total length/size � t FILTER BED ❑ ' ` Distance to nearest: Well Foundation Property Line SEEPAGE PITS-- ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 4 I hereby certify that I have prepared this application and that the work wilt 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 following: "I certify thatin the performance of the work for which this permit is issued, I shall not employ dry person in such manner as to become subject to workman5 compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that i;n'tFie performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applica us call for required in pections. Complete awin on reverse side. Signed X M.TatIe: Date: FOR DEPARTMENT USE ONLY Q� Application Accepted'by Area C) D Stk 466-6781 Additional Comments: 0 ❑ Lodi 369-3621 Pit or Grout Inspection by Date ; ❑ Manteca 823-7104 Final Inspection by Date g 26 L Tracy 835-6385 Applicant - Return all copies to; Environmental Heal Permit/Services 1 01 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ?PERM(IT N/0. INFO EH 13-24 REV. 10/82 � 10/82 500 14-26 _