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• APPLICATION FOR PERMIT 1.01 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S�cPRr (U�Cl�vn a>^ (Complete in Triplicate) 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 9801 Mof fat Blvd. Manteca Subdivision Name n/a Owner's Name Beall Trans-Liner Address 9801 Moffat Blvd. Manteca Phone 823-7129 Contractor's Name Manteca Plumbing QQ@nse No. 186808 Phone 823-2423 oG1 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing Lj Irrigation Approx. ❑ Eastern Depth Specifications ❑Cathodic Protection Depth of Grout Seal (_IGeophysical Type of Grout Lf Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial X— Other Number of living units: 0 Number of bedrooms 0 Lot size 2- 8 1 Character of soil to a depth of 3 feet: sandy loam Water table depth 12 ' SEPTIC TANK ❑ Type/Mfg existing tank Capacity 2 0 0 0 gal No. Compartments 2 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE [jk No. 8 Length of lines Ilt- Total length/size FILTER BED [k Distance to nearest: Well 1 Q0 r Foundation 631 Property Line 5 r SEEPAGE PITS ❑ Depth Size Number SUMPS F1Distance to nearest: Well Foundation Property Line' DISPOSAL PONDS ❑ 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 empl0y any person in such manner as to become subject to workman Is 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 yra 11 en 1166y ersons subject to workman's compensation laws of California." The applic 11 f a �I( d inspections. Complete drawing on reverse side. Signed X _ r Title: Owner Date: 1/27/84 fgR DEPARTMENT USE ONLY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by n Date ,_ y ❑ Tracy 835-6385 Applicant - Return all cop' to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFOY1 "_ -�-q W _ ' . EH 13-24 REV. 10/82 •�1 CT 10/82 500 14-26