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APPLICATION FOR PERMIT Q�� SAN JOAQUIN LOCAL HEALTH DISTRICT JUN 211983 313-57 7'7 1601 E. HAZELTON AVE.,AYESTOCKTON, CA N PERMIT NO. 1 3 r 5 ! 1 Telephone (209) 46b-6783 SJR 3O�Ay��Q� 3��qI� �� I E ISSUED PERMIT EXPIRES 1-YEAR FROM DATE ISSUED "�eJ7 !•J1 ffl4 ��r (Complete in Triplicate)- Application is her made'-to-the San Joaquin Local Health District for permit'to construct and/or install the work tierein 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,Loca) ealth District. Job Addresst�� { Subdivision Name Owner's Name Address. ,Q Phone (f 7 Contractor's Name .. SQ4J ,:License No. / /a Phone Z TYPE OF WELLIPUMP WORK: NE41 WELL WELL REPLACEMENT DESTRUCTION U ' PUMP-INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS fti� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U ' ' Industrial Open Bottom []Manteca ' Dia. *of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑Public G Other ❑Delta a Irrigation Type of Casing • V g Approx. Eastern Specifications � Cathodic Protection Depth P Geophysical -Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by t RepaiP Work Done Type of Pump .S H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/AbDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units; Number of bedrooms Lot size Character of soil to a depth.of 3 feet: Water table depth SEPTIC TANK Ej Type/Mfg Capacity No, Compartments PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM DESTRUCTION Distance to nearest: Well Foundation Property Line ❑ I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONOS 1 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 workmanh 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 applic must call fo a required inspections. Completed wi on reverse side. , Signed X Title: Date: Of EPARTMENT USE ONLY Application Accepted by , Area - � [] Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspectioh Date Manteca 823-7104 Final Inspection by — Date . E] Tracy 835-6385 Applicant - Return all copies to: Environment. Health Permit/Services 1 O1 E. H tan Ave., P:O. Box 2009, Stk., CA 95.201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. ]NFO f a{ 8 93-577 EH 13-24 REV. 10/82 10182 500 14-26 '