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2" APPLICATION F0a".` � L.1 all .. 0.J SAN JOAQLiIH PE= LOCAL HEALTH. 'DISTRICT SEP 191983 1501 E. HAZELTON AVE., STOCKTON, CALOCAL � IN, Telephone (209) 466-678``' �+;"nk, g PERMIT NO �! PERMIT EXPIRES 1 YEAR FROM DATE IS+S LTH DISTR T DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local HedIth 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 Lo ai Health District. g_<XAW_0 h-/ Job Address Subdivision Name Owner's Name Z j Address Phone ff W--3/3—il Contractor's Name . ft] License No. �'I Q j� Phone 83 ,-c2,2o`7 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER IJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation UJ Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public Cl Other Delta V irrigation Type of Casing g Approx. ❑ Eastern Specifications Cathodic Protection Depth p Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done Type of Pump S L4 -_ H.P. /� cJ 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 Installation will serve: Residence _ Commercial Other available within 200 feet.) O Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK U Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION Q LEACHING LINE iJ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line a SEEPAGE PITS ❑ Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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: "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 ust c 11 for r q 'red inspections. Complete drawing on reverse side. Signed X O� 9 Title: Date: MENT :�Ar,a Replication Accepted b Stk 466-6781 Additional Comments: y �-- Lodi 369-3621 Pit or Grout Inspection by Date 7aa3teca 823-7104 Final Inspection by Date —� -$3 ❑ Tracy 835-6385 Applicant - Return all copies to: Eno roan Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED . RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82V� f I 10/82 500 14-26