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r- — ff3� I APPLICATION FOR PERMIT / SANJOAQUIN LOCAL HEALTH DISTRICT 'tel 1501 ETelephone AVE., STOCKT66-678ON, CA PERMIT N0. o G� Telephone (209) 46fi-6781 A'YPF PERMIT EXPIRES I YEAR FROM OATE. ISSUED DATE ISSUED 9 (Complete in Triplicate).' 'r 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 Subdivision..Name w Owner's Nam yL /",.sl.C,4,WLL Address 1S�� Phone Contractor's Nam 149/sA,Or/i •License No. mai-3 S/.'1 Phone JV 6-96••0]' s1 ( TYPE Of WELL/PUMP,,WORK: NEW'WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` 'PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE . FOUNDATION .1 AGRICULTURE WELL OTHER WELL PITS/SUMPS — ,J INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑Domestic/private ❑Gravel Pack ❑Tracy Dia. of Well Casing 1 ❑Public Ej Other ❑Del ta. Type of Casing 4 ❑ irrigation . Approx. ❑Eastern Specifications f ❑Cathodic Protection Depth --Geophysical DepthofGrout Seal _ ❑ t Type of Grout ❑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 L1 (No septic tank or seepage pit permitted if public sewer is E available within 200 feet.), Installation will server Residence d' Commercial _ Other f I Number of living units: .". Number of bedrooms _Lot size y Character of soil to a depth of 3 feet: - .� /� Water table depth, /9po SEPTIC TANK PC "Type/Mfg Aou .9 ^ GQweL' Capacity 1ZOo No. Compartments PKG. TREATMENT PLT. ❑ Type/J•Incfg Capacity Method of Disposal SEWAGE SYSTEM Distae to nearest: Well, 00 Foundation _ Property Line DESTRUCTION C3 "I LEACHING LINE No. 6 Length of lines Z.@ 85 - Total length/size /70 .9 7- EEE! FILTER BED ❑ Distance to nearest: Well /ap Foundation Property Line SEEPAGE PITS ® DepthE21C' _ Size -43 Number L SUMPS IJ Distance to nearest: Well I!rb', Foundation Property One DISPOSAL PONDS . LI 1 A' I hereby certify that I have'pr;pared this application and that the work will be done in accortlance with San Joaquin county ordinances, state laws, and;rdles'and regulations of the San Joaquin Local Health District. W Hone owner or licensed agent',a`Esignature 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 workman4 compensation laws of California." Contractor's hiring or sub-c6ntracting•signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shaI4�einQlby persons subJect to workman's compensation 'laws of California." ..,4...,, The appl lcapt must call f al eququi ir in actions. Complete drawing onreverseside. r - Title:-.\ J' `Yci/Aea�✓' _ Date: 9"7 67 Signed .X r EPARTMENT USE ONLY` Application Accepted by sr Area II`tk 466-6781 Additional Comments: _ •=�r _ ❑ Lodi 369-3621 j Pit or Grout Inspection by �' J Date B� " Manteca 823-7104 fl! Final Inspection by Date 3 ❑ Tracy 835-6385 1 Applicant - Return all copies to:11Tiviyronmental Health 'mit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE BASE AMOUNT iO11F,; AMOUNT REMITTED RECEIVED BY GATE I p PERMIT N0. INFO -� - 10/82 500 �. EN 13-24 REV. 10/82f { 14:26 � "