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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTOTelephone AVE., ST-.6781 , CA PERMIT NO. S Q 7e7ephone (209} 466-b78i F PERMIT EXPIRES 1 'YEAR FROM DATEISSUED DATE ISSUED ft (Complete in Triplicate) ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work. described. This application is made in compliance with San Joaquin Count Ordinance No. 549 for sewage or No. 1862 forewell and the Rules and Regulations of the San Joaquin Local Health D9strict,1 y g well/pump Job Addressf7 �,g�y 1 ZZ t :) Subdivision,Name Owner's Name _ /,iJ� �C; �ry Address Contractor's Name Phone 1 _.ro"tr License No. - �' Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ p� 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 r n Industrial ❑OpenBottomManteca V ' ❑ Domestic/Private ❑ Dia, of Well Excavation 17 Public ❑Gra el Pack ❑ Tracy Dia, of Well Casing ❑ Irrigation E]Other ❑ Delta Type of Casio Approx. ❑ Eastern g ❑Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal ❑Other Type of Grout Repair Work Done e of Pumurface Seal Installed by S ❑ Type p H.P.HPState Work Done Well Destruction E] Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION g) (No septic tank or seepage pit permitted if public sewer is Installation will. serve: Residence Commercial _ Other available within 200 feet.) Number of living units: _/_. Number of bedrooms � Lot size 44X ,�� Character of soil to a depth of 34 feet: SEPTIC TANK Water table depth 0p p. Type/Mfg Capacity /�,�L, No. Compartments PKC. TREATMENT ALT, ❑ Type/Mfg Capacity ---�^ Method. of Disposal Distance to nearest: Well Foundation ^` property Line 2 D 1 i # LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [) Depth I Size SUMPS Number Distance to nearest: Well Foundation t DISPOSAL PONDS E:) �� Property Line y�c �oxfy �� 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 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 workmants 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." The applicant must call fo all equir ns ections. Complete drawing o revers side. Signed X ~ . Title: Date: Application Accepted by PART T USE ONLY Area F] Stk 466-6781 Additional Comments: Pit or Grout Inspection by ❑ Lodi 369-3621 Date ❑ Manteca 823-7104 Final Inspection by Date Applicant -6385 - Return all copies to: Environmental Health Permit/Services 1601-E. azelton Ave., P.O. Boxy200935Stk., i k , CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO TE ..�QQ PERMIT NO. qG0U�` f�� EH 13-24 REV. 10/82 `0"P Tm5p 13y 9-creats j_/0-S3 1 14-26 10/82 '500 [� M