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APPLICATION FOR PERMIT z „ SAN JOAQUIN LOCAL HEALTH DISTRICT ;;,• , .. . _ 1601 E. HAZELTON AVE., STOCif70N, CA PAYMENT � RECEIVED i Telephone (209) 466-6781 4 6 �— PERMIT EXPIRES 'f YEAR FROM DATE ISSUED AUG 1988 (Complete in Triplicate) AA�� ro^t�'��r,�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the vile* V1WNeeEWok9 ion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules ar [ �aE a�nlWaquin Local Health District. o"? S• G &Y ries- N�-ec ' S, '�` j , Job AddressQlC�y�� t G� Lot Size GYtfSPM Owner's Name 4 Address 0 C Slqf• Phone 7sZ, 31 Contractor 7le Ah Q 3. Address. ryll License No.1-21*77— Phone qZ. TYPE OF WEL P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Jq PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom 1K Manteca Dia. of Well Excavation Dia. of Well Casing (� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 FI Public Cl Other f7 Delta Depth of Grout Seal Type of Grout --- I f Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type.of Pump H.P. State Work Doonne—_ Well Destruction El Well Diameter Sealing Material Itop 50'1 -�;_d!21 L y Q !$, ba rV V.S.t/ Depth Filter Material (Below 50') —C;!k'w et� AY I I _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted it public sewer is rDr available within 200 feet.) , Installation will serve:- Residence Commercial_ Other y Q Number of living units: Number of bedrooms .g ; Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r. PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line x i LEACHING LINE ❑ No. & Length of lines I Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Cine i DISPOSAL PONDS ❑ 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 work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the part ma a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of or !I The applic a r'all req u i ions. omplete drawing on v rse side' Signed i e: Date: r FCM;DEPARTMENT USE ONLY Application Accepted by > �� L— Date /F_�`��r Area JJ Pit or Grout Inspection by Date Final Inspection by Date A Additional Comments: LG � r s� �! 10 11, ❑ Stk 466-6781 ❑ Lodi 369-3621 CI Manteca -7104 racy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo>�2009, Stk., CA 95201 i INFO FEE AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED 8Y DATE PERMIT NO. +.EH 1324 IpEY.i i n 51 EH t4-2a I i 1