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APPLICATION' FOR PFRMi i 8 (A SAN JOAQUiN LOCAL �RFALTH DISTRICT VA-1k.? p 1601 E. HAZELTDii ,AVE. , STOCKTCN, CH FEB 2 1 ��"�,` PERMIT N0. O � � ��7 Telephone (209) 466-6781 DATE ISSUED Z1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SM joAQUIN LOCAL (Complete in Triplicate) HEAUM DIST�Iff 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 Joaouin Local Heal h Di ict. 5E_Xp_� . Job Address � o o -�-Q Subdivision Name Owner's Name f Address /I/i ra t? Phone Contractor's Name " — 0 [ N License No. 3 0 Phone &!A '7 � TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION [� SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA Industrial U Open Bottom ❑ Manteca Domestic/ Private F_� Gravel Pack Tracy CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing L -i Public _ [Other ❑ Delta Type of Casing L_iIrrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth Depth of Grout Seal 17 Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: �_ Number of bedrooms Lot size � n /¢ [ y Character of soil to a depth of 3 feet: Water table depth [. SEPTIC TANK CJ_Type/Mfg d° o IV C R GTE Capacity 6 b © �'No. Compartments � � � � PKG. TREATMENT PLT. ❑ .Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation TO Property Line `s -O 1�T DESTRUCTION LEACHING LINE jJ No. & Length of lines FILTER BED Distance to nearest: Well Total length/size Foundation Property Line 1 SEEPAGE PITS Depth We Size p Number SUMPS Distance to nearest: Well Q_f FoundationProperty Line C_a� DISPOSAL PONDS ❑ C, R i m .�� t , c/tOV I D WOR L # D o b 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: "1 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 workman5 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 f r all required inspections. Complete drawing on reverse side. CA /_7 T_Ll Signed X C -Y, A. -'t 0 Tit-u:j V &- L°1 41 'Date: FOR EP NT U ONLY Stk 466-6781 "- Application Accepted by Area / Additional Comments: Lodi 369-3621 Pit or Grout Inspection y Date _- % - ay .1� Manteca 823-1104 Date ❑ Tracy 835-6385 Final Inspection by ' Applicant - Return all copies to: Ervironmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE . AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/82 500 Eh 13-24 REV. 10/82 14-26 FAA