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I's' APPLICATION FOR PERMIT SAN JOAQL'iN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781. ®CPERMIT EXPIRES 1 YEAR FROM.DATE ISSUED DATE ISSUED �pN a�AQUp►S�RIG�i 11,, (Complete in Triplicate) � IAcyy�C4a44 Applicati�Es`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 Q ip -Lodi Subdivision nn-Name Owner's Name -TO-0. Address 33 E I j -5r,- 44M Phone _3�1 �Z x Contractor's Name Plt once Orillps Drilling COfPkense No. Phone r TYPE OF WELL/PUMP WORK: �I?r NEW WELL ® WELL REPLACEMENT DESTRUCTION . PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTI TANK+ -V< SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , . } INTENDED USE' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS` I Industrial ff �k' a..� X.Open�._,8ottom _[].Manteca_4- •.D�a, of Well Excavation —�;^. f_. ,:, ,;�- --^--�-�'rte" �� LJ DomesticlPrivate i Gravel Pack Tracy Dia. of Well Casing Public Other [] Delta Irrigation L' Approx. ED Eastern Type of Casing ❑Cathodic Protection Depth Specifications V Depth of Grout Seal Geophysical U Other Type of Grout f Surface Seal Installed by f Repair Work Done E] Type of Pump � H.P. State Work Done Well'"Destruction U Well Diameter Sealing Material (top 50') _ e i Depth'i . ,ZOR, Filler Material (Below 50') r TYPE OF SEPTIC WORK:: NEW INSTALLATION EJREPAIR/ADDITION J (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 Character of soil _to_a_dkp.th--o_f, 3-f.eet.:. __ _ Water table depth SEPTIC TANK 1pe/Mfg, - ,. Capacity No. Compartments PKG. TREATMENT PLT. yType/Mfg Capacity Method of Disposal SEWAGE SYSTEM µ Distance to nearest: Well Foundation Property Line DESTRUCTION'. Q I� LEACHING LINE UNo. & Length of lines Total length/size f FILTER, BED-. ,F- Distance to nearest: Well Foundation - Property Line f SEEPAGE PITS I----Depth • -m- *., Size Number zDistance .to nearest: Well Foundation_ .Property Line € DISPOSAL PONDS I hereby certify t at I ha'v'e prepared this application and that the-.work will be done in accordance with San Joaquin county ordinances, state laws, an6 rules and regulations of the San'Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:-.iI,certify that in the performance of the work for which this permit is issued,-I shall not empTOy any person in such manner as to become subject to workmant compensation laws of California." Contractor's hiring or subtcontracting signature certifies the following: "I certify that in the performance of the work for which f this permit is issued, I shh ljmploy persons subject to workman's compensation laws of California." Ii The applic mvsf c br al required iMspections. Complete drawing on reverse side. Signed X E 9 I Title: Pre-5ide r- Date: i� OR ARTMENT 5E ONLV_ZyJJ- 4 Application epted by Area OZ Stk 466-6781 Additional CommentsMLodi 369-3621 Pit or y Date Grout;Ins ection b p � � Manteca 823-7104 Final Inspection bye ��r Date ./ . s Tracy 835-6385 Applicant - Return all copie to: Environmental Cealth Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .p. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO gs>>Li s - -s-I EH 13-24 REV. 10/82 ff 10/82 500 14-26