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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. �3-� �S <br /> 1601 ETelephone(209)466-67811N, CA S <br /> � DATE ISSUED. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P <br /> (Complete in Triplicate) � <br /> k <br /> Application is sherebyapplication <br /> icatiooishmadenin°compliancelwithlth SanOistrict for a J Joaquin countypermit to OdinancecNo. 549tfordsewageinstall <br /> o 1 herein <br /> described. This app <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> t1 Subdivision Name cf�a <br /> Sob Address f� LrAl/v Phone <br /> Owner`s Name 11j I Or Address Z G �� <br /> Phone <br /> Contractor's Name f rh/ � G/��f�� License Na. <br /> TYPE OF WELL/PUMP WORK: NEWWELL ❑ WELL REPLACEMENT E] DESTRUCTION <br /> ❑ <br /> PUMP INSTALLATION F1SYSTEM REPAIR ❑ OTHER ❑ <br />� SEWER LINES DISPOSAL FLD. PROP. LINE __.. - • <br /> DISTANCE,TO NEAREST: SEPTIC TANK 'I OTHER WELL PITS/SUMPS <br /> FOUNDATION 1 AGRICULTURE WELL <br /> E <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATIDNS • <br /> i ❑ Industrial [—IOpeh,.Bottom El Manteca of Well Excavation Manteca , <br /> ❑ Domestic/Private ❑Gravel Pack Tracy Dia, of Well Casing <br /> � <br /> ❑❑ Public [j Other Delta Type of Casing <br /> Irrigation TApprox. ❑Eastern Specifications = <br /> Depth Depth of Grout Seal 4 <br /> � ❑Cathodic Protection {" <br /> ❑Geophysical Type of Grout <br /> ❑Other ' Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump# N.P. State Work Done <br /> Well Destruction E] Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 5O') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION E3 (No septic tank or seepage pit <br /> avai ableewithiif nu200cfeet.)sewer is <br /> l <br /> Installation will serve: Residence V/ Commercial Other Z ,,,,, <br /> Number of bedrooms —Lot size p C rE S .- <br /> { Number of living units: �^ r�r <br /> k / Water table depthZ- <br /> Character of soil to a depth of 3 feet: /� W=VC, <br /> No. Compartments' <br /> SEPTIC TANK ❑ Type/Mfg pacity <br /> Capacity Method of Disposal <br /> PKG. TREATMENT PLT. 17TYPe/MI9 i Property Line <br /> Septic Wank Distance to nearest: Well Foundation. <br /> Destruction <br /> No. & Length of lines TctaI.1ength/size 2 7 D <br /> LEACHING LINE I g Property Line <br /> FILTER 3EO ❑ Distance to nearest: Well Foundation r <br /> SEEPAGE PITS Depth Size Number <br /> EJ -- <br /> fM Foundation Property Line <br /> SUMPS LJ Distance to nearest: Well1. <br /> DISPOSAL PONDS ❑ , <br /> I hereby certify that I have prepared this application and that the work wil-l•`be done in accordance with San.Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, 1 shall not employ any person in such manner as to become subject to workman compensation laws of California."i <br /> Contractor's hiri r sub-co ratting signature certifies the following: "I 'certify that in the performance of the work for which <br /> this permit is d, i sh 1 employ persons subject to workman's compensation laws of California." <br /> The applica' ust cal} 11 required inspections. Complete drawing o reverse side. Date: 'f <br /> Signed X ! l Title: <br /> Fp ARTMENT USE ONLY ©7 ❑ Stk 46fi-6781 <br /> Application Accepted by ...: Area <br /> ❑ Lodi 369-3621 <br /> Additional Comments: ❑ Manteca B23-7104 <br /> Pit or Grout Inspection�by � DateFinalInspection by <br /> Date d 7?�W. Tracy 835-6385 <br /> Appiicant - Return all copies tv �alHeal�thPEit/Ser ices 1601 E. Hazelton Ave., <br /> P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE OUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT N0. <br /> INFO <br /> 10182 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />