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APPLICATION FOR PERMS <br /> SAN JOAQL IN LOCAL n,SLTH JiSTRICT <br /> r PERMIT NO. <br /> 1601 E. HAZELTOTelephone <br /> AVE., 66-678ON, CA <br /> Telephone (209) 466-6181 DATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> I` (Complete in Triplicate) <br /> Application is herE4 made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> V and the Rules d pgu attii-ogV5 of tine Joaquin ccaa- a[J,� �he(all�thh DDiis��{�ict. <br /> Job Address d O ! „ate � '^ -ion Name yL� �jrs <br /> Address Phone <br /> Owner's Name !,/1 - -C �7 A ' Phone _— <br /> �..,%n <br /> ` Contractor's Name G/ License No. _ y <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �I .tU <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER V_ <br /> SEWER LINES. DISPO /� PROP. LINE _ ( <br /> DISTANCE TO NEAREST: C TANK IER WELL �1..�. PITS/SUMPS <br /> FOUNDAT AGRICULTURE WELL <br /> y,�V PROBLEM AREA TRUCTION SPECIFICATIONS <br /> 1. INTENDED USE open <br /> OF Dia. of Well Excavation <br /> -- ❑ Industrial ❑ Open Bottom Manteca <br /> ❑ <br /> �� Domestic/Private �Gravel Pack Dia. of Well Casing <br /> ; <br /> M Public Other elta '�� Type of Casing <br /> A ❑ Irrigation Appro Q Eastern ficat ions CL <br /> n�1_ ❑Cathodic Protection <br /> D - Depth Seal <br /> 1 ❑Geophysical Type of Grout <br /> r <br /> ❑ Lcl <br /> Other Surface Seal Installed by h <br /> Repair Work Don Type P <br /> T e of Pum �= M H.P. 5 State Work Done <br /> Well Destruction ❑ Well Diameter _ Sealing Material (top 50') <br /> • <br /> Depths Sf0 f Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ) REPAIR/ADDITION ❑ (No septic tank or seepage P�avai ableewithinu200c feet.) is <br /> r Installation will serve: R 'dente _ Commercial Other C / <br /> Number of bedrooms Lot size r __ <br /> Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: I 6(' No. Compartments _fl— , <br /> Type/Mfg Cru h e Capacity p <br /> SEPTIC TANK '7— <br /> Capacity Method of Disposal <br /> ` <br /> PKC. TREATMENT PLT. ❑ Type/Mfg Property Line <br /> SEWAGE SYSTEM C] Distance to.nearest: Well Foundation <br /> DESTRUCTIONZ2 inL / <br /> size _ <br /> LEACHING LINE l[ No. 8 Length of lines o2 ].A_Z 5 1 die; CA tai e g i <br /> Foundation Property Line <br /> FILTER BED E] Distance to nearest: Well <br /> $1Z <br /> q 3 Number <br /> Depth � <br /> SEEPAGE PITS �I p —�=-- / L� Property Line / <br /> SUMPS U Distance to nearest: Welll F Foundation <br /> �' - ---- <br /> DISPOSAL PONDS ❑ <br /> i.. ordinancor which this <br /> esreby erstate laws( anderulesaand regulatipnsation of then Sao Joaquinat the work Localill be Healthdone in District�cordance with San Joaquin county <br /> nc <br /> Home owner or licensed agent's signature certifies suchfmannernas to become subjecthat t tohworkmanerfo�compensationwlaws ork fof California." <br /> permit is � sued, I shall not employ any p <br /> th permits <br /> i hiissued, IushallnW5r- ring or tractin9 persons sect fiesto the following:sat ionrlaws ofaCaliforniyerfonnance of the work far whit <br /> employ <br /> � T appl ica9N us call for all pgquire spections. Complete drawing on reverse side. Date: <br /> •7�C —sty�U Title: CYCC lri <br /> Y fi✓ <br /> Signed % 1 <br /> F PARTi�T USE ONLY Area �y�.Stk 466-6781 <br /> Jw� Qom.— /`• <br /> ` Application Accepted by r -- ❑ Lodi 369-3621 <br /> Additional Comments: Date / -'4 X33 L—], Manteca 823-7104 <br /> d�por Grout Inspection by Date �8�9 g ❑ Tracy 835-6385 <br /> Final Inspection by CA 95201 <br /> Applicant - Return all copies t nvironmen al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., <br /> FEE I BASE DUE AMOUNT REMITTED <br /> RECEIVED BY DATE <br /> AMOUNT PERMIT N0. <br /> INFO dP <br /> ` R <br /> t1 I 10/82 500 <br />