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%00/ APPLICATION FOR PER" T SAN JOAQL:: LOCA_ ti,__-LTH DISTRICT 'q 1601 E. lephone AVE., STOCKT66-618ON, CA PERMIT N0. Telephone (209) 466-6?81 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 th San Joaquin Local Health District. Job Address C r Subdivision Name Owner's Name A.4k ,S dress )f0/0 9/• Phone I ( - F0 Of Contractor's Name L�-e-�� >vp/ License No. /4 _373 Phone r. 3 a TYPE OF WELL/PUMP WORK: NEW WELL L] WELL REPLACEMENT DESTRUCTION [ "- PUMP INSTALLATION F-] SYSTEM REPAIR [ OTHER EJ w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial D Open Bottom ❑Manteca Dia. of Well Excavation j Oomestic/Private r_J Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing [j Irrigation Approx. ❑Eastern EJ Cathodic Protection Depth Specifications - Depth of Grout Seal EJ Geophysical Type of Grout ❑Other � Surface Seal Installed by 1A �y— ,..� Repair Work Done a Type of Pump ( H.P. ' State Work Done roL- If.t— Well Destruction ❑ Well Diameter " Sealing Material (top 50') _ Depth Filler Material (Below 50') 7-y TYPE OF SEPJIC WORK: NEW INSTALLATION [I REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is d 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 ❑ 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. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [_J Depth Size Number SUMPS [j Distance to nearest: Well Foundation Property Line DISPOSAL PONDS [I 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. Hone 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 workman§ 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 appl is ust all f required i pec t ions. Compl et awin�-+cn reverse side. Signed X Title: fit/ Date: FOR DETMENT USE ONLYp Application Accepted by -�YfFA'J Area ! [ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date [ Manteca 823-7104 Final Inspection by Date .�y pj ❑ Tracy 835-6385 Applicant - Return all copies' to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., LR 95201 rIFEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. NFO � '-) EH 13-24 REV, 10/82 10/82 500 14-26