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:^I, JG^�'±:1=-. �°J l,.r._ _-..i�'• .i.s :Cit.! �7�. 15Gi E. HrZELTU?i .yyE SY0' '.D?J, A PERMIT NO. Q -6� Cf, Telephone (209') 466-6751 DATE 1ssuED PERMIT EP1RE5 1-YEAR FROM Ll,,�-E 'SSUEu (Complete in Tripl-ca�e) E� 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. 1662 for well/pump i and the Rules and Regulations of the San Joaquin Local Health District. Job Address 0�bdivision Name G Dwner's Name y��✓ T/�/�HSLr�/ Address �,�//09 Phone .�G? ( p Contractor's Name License No. PhoneF' ^^�� TYPE OF WELL/PUMP WORK: NEW WELL CI WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I_I i �{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE ' E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI^N SPECIFICATIONS Industrial ❑ Open Bottom [] Manteca Dia. of Well Excavation ' ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Dia- of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing �jIrrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout I❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done - Fj Well Destruction F-1Well Diameter Sealing Material (top 50') Q 7 Depth Filler Material (Below 50') tf TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AODITION X (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence -),� Commercial _ Other Number of living units: —/— Number of bedrooms / - Lot size 4Z- Character of soil to a depth of 3 feet: Water table depth X{ SEPTIC TANKj T Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well / Foundation Property Line r- DESTRUCTION _ LEACHING LINE ❑ No. & Length of lines Total length/siz T .SSU Vel FILTER BED ❑ Distance to nearest: eIl C Foundation Property Line / P SEEPAGE PITS CI Depth Size Number SUMPS Distance to nearest: Well _Z 4 ;� FoundationProperty Line DISPOSAL PONDSrill ❑ 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 Heath District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this ermit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California-" P that in the performance of the work for which Si nature certifies the follow^ng: "I certify t a Contractor's hiring or sub-contracting 9 this permit is issued, I shall employ persons subject to workman's compensation laws of California; The applicant ust call for all required inspections. Complete drawing on reverse side. / Z2-Fj y� � Signed X �� stll>�" Title: Date: E M NT /��ONLY J 2 Application AcceptedMF �-f�G� Area / .7 ❑ Stk 466-6781 u ❑ �'Z Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date t ❑ Manteca 823-7104 L Final Inspection by Date ❑ Tracy 835-6385 > !� cL d!✓ i Applicant - Return all copies to: Environmental Health llermit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 4 FEE BASE AMDUNT DUE AMOUNTREMITTED RECEIVED BY DATE PERMIT N0. ani 0 f %J INFO r3 a�.- Gwn-crr s 0l62 0( // Ls—Y i Fj EH 13-24 REV. 10/82 14-26 fOh uvil�C4117 S F3