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LO faLp)e APPLICATION FOR PERMIT i SAN 9 LOCAL, HEALTH DISTRICT C. HA .p-` 1601 E. HpZELTON AVE., STOCKTOtt, CA PERMIT N0. 0 Telephone (209) 466-6781 D 3 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . - ' (Complete in Triplicate) - Application is hereby made to the Sa;'Joaquin Local Health District Ifor 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 Local Health District. -Job Address TOO Q - Ct y-yk s`t Subdivision Name Owner's Name [4dyQ �end tSfdy RANT Address 0 w.1 Phone Contractor's Name -S*& g&Iy License No. Phone , TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U '� PUMP INSTALLATION ® SYSTEM REPAIR LJ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,- DISPOSAL FLO. PROP. LINE ! ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ _�71 INTENDED USE TYPE OF WELL PROBLEM AREA 3 *CONSTRUCTION SPECIFICATIONS HCl 0 Industrial [—J Open Bottom ❑Manteca Dia, of Well Excavation LJ Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing Public —1 Other ❑Delta Type of Casing _ .— Li Irrigation Approx. Eastern Specifications Cathodic Protection Depth — Depth of Grout Seal Geophysical Type of Grout Other Surface Seal Installed by Repair-Work Done �] Type Pump 1LyJk1;.p H.P. SC. - State Work Done Well Destruction Well Diameter Sealing Material (top 501 — Q Depth Filler Material (Below 501) h TYPE OF SEPTIC WORK: NEW INSTALLATION RBPAIR/ADDITION [J (No septic tank or seepage pit permitted if public sewer is �f available within 200 feet.) Installation will serve: Residence _ Commercial _ Other . Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3'feet: - Water table depth SEPTIC TANK [—j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg '- Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. 6 Length of lines - Total length/size �_ Distance to nearest: Well Foundation Property Line / FILTER BED � SEEPAGE PITS Depth Size s Number SUMPS p Distance to nearest: Well Foundation Property Line DISPOSAL PONDS - r 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 workman4 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." p. The applicant must call;or all it r j0PART a Complete dsa=ing on reverse side. Dater a� 0 3 Signed > � tM1 title: {(Lit R ENTUSE ONLY ^�j C3 Stk 466-6781 Lt -f Area _�_ . C] Lodi 369-3621 Additional Camnents: L7 Manteca 823-7104 Pit or Grout inspection by Date e Final Inspection by 4 _Date 0 3 ' p Tracy 835-6385 Applicant - Return all copies to: EAironmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., LA 95201 FEE I BASE . J4AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATES � �q PERMIT N0. INFO . 4 3 3b 0.J 0 311 10/82 500 Q EH 13-24 REV. 10/82 14-26