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Jl l ! 26 v APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT ' I 1601 E. HAZELTON AVE.,'STDCKTON, C MAY �f I Telephone (209) 466-6781 y DATE ISSUED PERMIT EXPIRES 1 'Y EAR FROM DATE ISSUED � �� LL � te in Triplicate} �,�,. T bfo— Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein l ,,Sdesc r i bed. This application is made in compliance with San Joaquin County Ordinance No., 549 for sewage or No. 1862 for well/pump �j and the Rules and Regulations of the Sar Joaquin Local ,Health District. � Job Address McDonald .Islrand subdivision Name J Owner's Name Zuckeman-Mandeyi11e,Inc. Address P.O. Box 487, Stockton, CA Phone (209 465-2673 ik Contractor's Name Same - License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F_� DESTRUCTION U PUMP INSTALLATION �5' SYSTEM REPAIR OTHER U 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 IJ Industrial ❑ 0pen 0ottom F] Manteca Dia. of Well Excavation Domestic/Private F-1 Gravel Pack ❑ Tracy Dia, of Well Casing Public Other Delta - - Type of,-Casing r = - �►-=-= --_ - ^� -V'[rrigatibn Approx. [] Eastern De Depth Specifications Cathodic Protection p Geophysical Depth of Grout Seal LJ LJ Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pumpc2ntriflcal.P. 1 1/2 State Work Done ` Well Destruction U Well Diameter: Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other o Number of living units: [Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK Type/Mfg Capacity No. Compartments 1 {I PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal ) . a SEWAGE SYSTEM Distance'to nearest: Well Foundation Property Line DESTRUCTION ❑ ; LEACHING LINE U No. & Length of lines Total length/size FILTER BED DistanceF,to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line d DISPOSAL PONDS �I..hereby_certif"y-that:-I-have�prepared,.this application and that.the work.wiT1 be done in accordance with San Joaquin county ordinances, state laws, and rules and"regulations of the San Joaquin LocaT Health Disfh ct�` 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 workman 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 applica t u i fol 1 it inspections. Complete drawing on reverse side. Signed x Title: Office Manager Date: 5/24/83 FOR D A TMENT USE ONLY - Application Accepted by Area eg Stk 466-6781 Additional Comments: L] Lodi 369-3621 Pit or Grout Inspection byDate Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Anvironmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEFPERMiT NO. INFO S . J1 -L{ S EH 13-24 REV. 10/82 10/82 500 14-26 !