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APPLICATION+FN PERMi-, SAN JOAQUiN LOCAL-HEALTH DISTRICT q ///�� / 1601 E.Telephone AVE., STOCKT66-678ON, LA PERMIT N0.O � Telephone (209) 466-fi781 - DATE ISSUED -T J i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I JIJ (Complete in Triplicate) 11 Application is hereby made [o 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. /' T` ,f+,., 1 }- Job Address 275 Subdivision Name Ce rb y��A'S'•/�/ , ate'+ Owner's Name Address 49.Y49/ J C S Phone 'RRA 3 u 00 Contractor's Name 1/_ License No. /795706 Z� Phone -3 g/- �80 TYPE OF WELL/PUMP WORK: w NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ u - PulpINSTALLATION .❑ SYSTEM REPAIR OTHER U W - DISTANCE TO NEAREST: SEPTICJANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 C FOUNDA4 ION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑Marteca Dia. of Well Excavation - { ❑Domestic/Private Gravel Pack ❑Tr cy/ // Oia. of Well Casing ❑Public Other I�WB'�Yd � Type of Casing L) Irrigation �_Approx. ,17 Depth Specifications ❑Cathodic Protection � Depth of Grout Seal Q Geophysical Type of Grout ) ❑Other Surface Seal Installed by Repair Work Done Type of Pump M.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depths! Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONf: REPAIR/ADDITION ❑ (No septic'tank or seepage pit permitted if public sewer is i f A available within 200 feet.) -rr� Installation will serve! Residence Commercial k Other v Number of liv4d'g units: 'Number of bedrooms Lot size r.i Character of soil to a depth of 3Y'feet: �/ 2( Water table depth s �• s SEPTIC TANK ` t� Type/Mfg Capa 'ty Z.l9n 1 No. compartments - J w:. PKG. TREATMENT PLT, [I 'Tsape/Mfg Capa "ty Method of Disposal SEWAGE SYSTEM stance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE Ito.-8 Length bf. lines � Total length/size ( O ) FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS -fepth �•r Size LJaf( Number l SUMPS 1J 9istance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ T -., Ag,(/e 1 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. I 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 dot employ any person in such manner as to become subject to warkman5 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 sAall employ persons subject to workman's compensation laws of California." The applicann must call for ill required nspection Complete dra ng on r ve�yaje side. �/ C-0^11" ;Signed x / !/�Al& d LP�l � `J�2 Title: �i"' ��"- L7�• ate: ;a R 'EPA ENT ONLY ��— Application Accepted by _ _ _ - „_- -Area,. ------ F Stk 466-6781 Additional Comments - Lodi - 369-3621 r Pit or Grout Inspeca ion by Date 1y/-' ❑ Manteca 823-7104 _.r Final Inspection by - Date /I-Z"V ❑ Tracy 835-6385 - k Applicant - Return all cop as to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 r INFO I BASE A�OUNT DUE - AMOUNT REMITTED RECEIVED BY �T�� noo 5 < V EH 13-24REV. 10)62 10/82 500 r• a•f -�J ,5� - 14-26 - .. �.iT� t0 -. S.