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APPNZ LICATION',FOR PERMIT it SAN JOAQUIN•LOCi�tEALTii DISTRICT i n —D,-1601 E. HAZELTON AVE., 5TOCKTOh, CA 6 PERMIT NO. Telephone (269) 466-6781 !r � DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S/ (Complete in Triplicate) ' Application is 4haty madjto 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 Regulati n Ir. ocal Health District. Job Address �r/0 /1 Subdivision Name �[Qr Owner's Name—lp Address BsV QW Phone Contractor's Name L'1L License No. qD "Z, Phone .54U VC U Efl TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE QQ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r❑ Industrial !I❑Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private i!❑Gravel Pack ❑ Tracy Dia. of Well Casing _ Public Other Delta ,I ❑ ❑ ❑ Type of Casing �❑ Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth ti❑ � Depth of Grout Seal � ❑ Geophysical Type of Grout Other LJ Surface Seal Installed by Repair Work Dane ❑ Type"of Pump H.P. State Work Done k r Well Destruction ❑ Well ;Diameter Sealing Material (top 50`) _ Depth Filler Material (Below 50') s TYPE OF SEPTIC WORK: NEW`!INSTALLATION REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is -V i available within 200 feet.) Installation will serve: Residence Commerciale Other Number of living units:!!] Number of bedrooms Lot size !l { k Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ;Type/Mfg fp/4 Q.Q •3 Capacity No. Compartments I. s� I PKG. TREATMENT PLT. E] `Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM C] Distance to nearest: Well Foundation Property Line DESTRUCTION ` i LEACHING LINE "No. & Length of lines l e Total length/size f� IN il FILTER BED ❑ ',Distance to nearest: Well Foundation Property Line I' SEEPAGE PITS ,!I Depth ' _ Size "T Number SUMPS ❑�, 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ `",4 i' 11 Ihereby 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 E ` permit is issued, I shall' not employ any person in such manner as to become subject to workmant 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 11 ploy persons subject to workman's compensation laws of California. The applicant mus fo required inspections. Complete drawing on reve s d t Signed X Title: * TDate: FOR D ARTMENT USE ONLY Stk 466-6781 lication Accepted by Area Additional Comments: Lodi 369-3621 Pit or Grout Inspection ; Date ❑ Manteca 823-7104 Final Inspection by rff J t .P/(/ Date % V ❑ Tracy 835-6385 n Health Permit/Services 1601/E. H zelton Ave., P.O. Box 2009, Stk— CA 96201 r Applicant - Return all copie to: Environme taJ ' 1 FEE BASE 'AMOUNT DUE AMkNT REMITTED RECEIVED BY DATE PERMIT NO. INFOC, 3 Q?�Ia M 10/82 500 :., fiN 13-24 REV. 10/82 14-26 lQ - -4