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I APPLICATION FOR PERMIT I SAN JOAQUiN LOCAL HEALTH DISTRICT f �7 1601 E HAZELTON AVE., 576CKTON CA PERMIT NO. Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � - � � DATE ISSUED,, .. `l, jIT Triplicate) (Complete in Tripl elf_ G�'-�.�-C•�� ,`—'Y� t. - 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 and the Rules and Regulations of the San Joaquin Local Heal h istr.ic g /pump .. I �t1 Job AddressyZ' j'. f, L l�L�_ pI 3u l o am IS�.hJ� r -Owner's Name 4JGKU�Lp-+'/S.ai- lr M11►3b 111L Address �Ct $ -y�4�ra..� Phone Contractor's Name' 1 c 4 License No. Phone ! TYPE OF WELL/PUMP.WDR K NEW"WELL ❑ s WELL REPLACEMENT ❑ DESTRUCTION ❑ �� PUMP.INST++ALLATION ❑ } ;SYSTEM REPAIR ❑ OTHER ❑ Com} `-DI i STANCE TO NEAREST: SEPTIC TANK 3 SEWER.LINES DISPOSAL FLO. PROP. LINE i FOUNDATION 1. AGRICULTURE WELL OTHER WELL PITS/SUMPS n, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r`}J Industrial ❑ Open Bottom Manteca Dia. of Well Excavation v } ❑ Domestic/PrivatePack�;.❑ Gravel Trac f ❑ Y Dia. of Well Casing ❑ Public's �J Other i ❑ Delta Type of Casing Lj Irrigation A ro pp x. E] Eastern ispecifications ❑Cathodic Protection Depth % Geophysical r e Depth of Grout Seal ❑ other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done ! ' Well Destruction ❑ Well Diameter Sealing Material (top 501) j Depth Filler Material (Below 50') = 4f TYPE OF SEPTIC WORK: NEW INSTALLATION FZ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Installation will serve: Residence Commercial X_ Other Number ofeliving-units: 4 Number of bedrooms e•40 Lot`sizel, r 5d •ri--" ,s "a Character of soil to a depthfof 3 feet: I IL—; _ Water table depth ) SEPTIC TANK Type/Mfg jacity 1200 No. Compartments _ PKG. �TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest:- Well r Foundation Property Line o- DESTRUCTION ❑ t LEACHING LINE No. & Length of lines �a Total length/size r FILTER BED U Distance to nearest; Well Foundation Property Line SEEPAGE PITS Depth f Size Number SUMPS ❑I Distance 'to nearest: 'Well Foundation Property Line DISPOSAL PONDS C 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. *-, n + Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this F 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 fallowing: "I certify that in the performance of the work for which r this permit is issued, 1 shall employ persons subject to workman's compensation Taws of California." k The applican st call for all . 'red ns tions. Complete drawing on reverse side. / c ` Signed X � Title: Q 5- y — Date: DEPARTMENT USE ONLY App .cation Accepted by Area ® Stk '466-6781 F Additional Comments: V ❑ Lodi 369-3521 . Pit or Grout Inspection by Date ❑ Manteca 823-7104 4 r Final Inspection by Date L7 Tracy 835'-6385 7 Applicant - Return all copies to: . E onm rental Health Permit/Services 1601 E. Hazelton Ave., P:O. Box 2009, Stk., CA 95201 - FEE BASE AMOUNT DDE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 w ! e ��(� '�' [ 10/82 500 14-26 y