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(Lr�� '�,J/j o %, /PLICATION KATION FOR PERM,? D%CC �w�y SAN JOAQLiN: LOCAL HEALTH D1 1601 E. HAZELTON AVE., STOCKT N, J [E '!Q$'7 PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR FROM �WENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to the San Joaquin Local Health 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 Local Health District. Job Address Qi / /y� ppiQ*l'Name Q� e — Owner's Name �7CfIL� `7�A�-S �y ` /f�eZ�y'—'�"— Phone Contractor's Nameitense NO. 071 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION I7 .. - PUMP -INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF 'HELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation IJ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public F—jOther ❑ Delta Type of Casing -- Lj Irrigation Approx. ❑Eastern Specifications -- ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout /' Lj Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done F. Well Destruction Well Diameter __-IQ--- Sealing Material (top 50') rhe.rrE u -- Depth _amZ� Filler Material (Below 50') cdaclE TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION [-j (Noseptic tank or seepage pi available within 200cfeet.) is Installation will serve: Residence — Commercial _ Other - Number of living units: Number of bedrooms Lot size Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK )_] Type/Mfg (� PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation _ Property Line - DESTRUCTION LEACHING LINE a No. a Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number - SUMPS Cj Distance to nearest: Well Foundation Property LineN DISPOSAL PONOS ❑ ' ' I hereby certify that I have prepared this application and that the work will be dgne in accordance;with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dor which this Home owner or licensed agent's signature cies thesucfollowing:manner as to become subject On District. ectt_the performance ance of the tionwlawsorkfof California." permit is issued, I shall not employ any person Contractor's hiring or sub-contracting sighature certifies the following: "I certify that'in-the performance of the work for whit this permit is issued, I Ihall employ persbns subject to workman's compensation laws of California." The applicant st 11 for all uired inspections. Complete drawing on reverse side. Date: Signed X - _Title: DEPARTMEN USE NLY Area 1 b ❑ Stk 46fi-6781 Application Accepted by 1-- t ❑ Lodi 369-3621 - Additional Comments: 1e+ �� '�"`� ❑ Date Manteca 823-7104 Pit or Grout Inspection by Tracy 835-6385 Final Inspection by _� Date ("a O C] P.O. Box 2009, Stk., LA 95201 Applicant - Return all copies to: Environmental Healtff Permit/Services 1601 E. Hazelton Ave., FEE I BIv' E ED 0.EC AMOUNT DUE AMOUNT REM III BY DATPERMIT NO. [E Tf INFOUO .'1 i � 41 10/82 500 EH 13-24 REV. 10/82 14-26