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40 " vk-YD APPLICATION FOR PERMIT n SAN JOAQUIN LOCAL HEALTH DISTRICT Abih LM{ I JNQv_ 1601 E. HAZELTON(ADVE 9)'4S OCKTON , CA PERMIT NO.Telephone PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED.�Tj/,2]lZ (.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 232 ;a- S7Oit.1 �� C �f4 Subdivision Name Owner's Name a E CL_AmK Address awrox Contractor's Name i. ? Phone •� 4 Z a License No. Phone ^� W j TYPE OF WELL/?UMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION [ SYSTEM REPAIR ❑ OTHER EJ ? DISTANCE TO NEAREST: SEPTIC TANK � - SEWER LINES � DISPOSAL FLD. PROP. LINE r'' ' F FOUNDATION AGRICULTURE WELL CP OTHER WELL PITS/SUMPS INTENDED USE 17 TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom EJ Manteca. .. a t Dia. of Well Excavation 1-1 Domestic/Private <El Gravel Pack-- Trac � ❑Public� � ;❑ Y't• Dia_ of Well Casing ❑Other ;E] Delta J x L] Irrigation A rox. 'Type of Casing Approx. ❑ Eastern ❑ Cathodic Protection Depth ; } Specifications ❑ Geophysical `•� Depth of Grout Seal U Other ` s Type of Grout i Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction .U` Well Diameter Sealing.Material.(•top 501) Depthr Filler Material .(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION fJ y REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is T' Installation will serve:. Residence �( Commercial — Other+_ available within 200 feet.) f� Number of living units: �_-_ Number of bedrooms „ Lot size fz4 v, 1S Character of soil 'to a depth of 3 feet. ^/ . • N SEPTIC TANK Water table depth �•Y� f Type/Mfg �� Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Ca ac itY Method of Disposal P Distance to nearest: Weil Foundation /Q� Property Line $21p LEACHING LINE ( No. & Length of lines ^- '20 a Total length/size FILTER BED ' ❑ Distance to nearest: Well '7!r Foundation /Y-4. Property Line /�j SEEPAGE PITS ❑ Depth Size Number , SUMPS U 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 of the San Joaquin Local Health District. 7l Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this i permit is issued, I shall not employ any person in such manner as to become subject to workman� compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "T certify that in the performance of the work for which this permit i issued, I shall employ persons subject to workman's compensation laws of California." The applic t s _call fo all requ' d ins tions. ,Complet drawing on reverse side_ - Signed X Title: _elle__ Date: Application Accepted by FOR DEPARTMENT USE ONLYArea Additional Comments: 5tk 466-6782 Pit or Grout Inspection by ,?� E] Lodi 369-3621 t Date Manteca 823-7104 Final Inspection by _ Date ❑ Tracy 835-6385 Applicant - Return all copies to; E lironment�alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO _ f EH 13-24 REV. 10/82 16 L2:7 14-26 10/82 500 `