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APPLICATION FOR PERMIT IT 2 { SAN .OAQUiN LOCAL HEALTH DISTRICT 1601 E. HRZE.LTON AVE., STDCKTDN, CR PERMIT N0. b y Telephoriea(209) 4666781 SAN J9AQU;N LOML ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3 HEALTH DISTRICT } (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereih 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 10633 N. Hildreth. Lane Subdivision Name Morada Owner's Name George Ke,ihn Address 2011 W. Lincoln .Rd Phone 477-9875 Contractor's NameMoormant S Water S s;fceaw;No. 267696 Phone 931-3210 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: ',SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S Industrial z ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C ❑ Domestic/Private ❑Gravel Pack Tracy Dia, of Well Casing ❑ Public r [1 Other ❑ Delta Type of Casing Lj Irrigat-ion Approx. E] Eastern{ Depth Specifications Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout f F1 Other Surface Seal Installed by k Repair Work El Type of PumpSubmerSllpje 2 State Work Done replaced existing pump f Well Destruction ❑ 3well DiameterMaterial. (top Sealing Material (top 5C') . ._ �' - - —--- .. 7 Filler Material (Below 50') C> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) 4` Installation will serve: Residence _ Commercial Other ` (� Number of-,1-iving units: # Number of bedrooms Lot size (,1 Character of soil to a depth of 3 feet: Water table depth vv�� SEPTIC TANK � ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Type%Mfg Capacity Method of Disposal i SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION 1 ' LEACHING LINE. U No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well f Foundation Property Line SEEPAGE PITS FD Depth Size ! Number SUMPS Distance to nearest:x Well 1 Foundation Property Line DISPOSAL PONDS ❑1 " 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. Home owner;or licensed agent's signature certifies the following: "I certify that in the performance of the werk'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." Contractdr'-s'hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which ,this permit is issued, ]'shall employ persons subject to workman's compensation laws of California." 1 The applicant must call for allre inspections: Complete drawing on reverse side. .r Signed XI _7.itle:_ _ ?tem `f FO PARTMENT USE ONLY n � Ap ?cation Accepted by i �/ � Area -___ St k, 466-6781 Additional Comments: +. Lodi 369-3621 V ` Manteca 823-7104 Pit or Grout 'Inspection ''Date Final Inspection by �� — W d`. Date — �� w ❑ Tracy 835-6385 F Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haze ton Ave., P.O. Bax 2009, St k., CA 95201 i 4127 FEE BASgEt AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO S 1.1-1 - 23 X33-J��a EH 13-24 REV. 10/82 10/82 500 14-26 ` /