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DAPPLICATION FOR.PERi�i7 . SAN JOAQUiN LOCAL HFALTH DISTRICT AUG 2 31983 1601 E. HAZELTON AVE., STOCKTGN, CA PERMIT N0. Telephone (209) 466-6781, DATE ISSUED SAN '{ �rQ�� LOCAL ;.PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED HEALTH DISTRICT,..i (Complete in Triplicate) to rein l th Application is hereblicationoishmadeninocomplianncelwith SanDJoaquin Countistrict for ay Ordinance ermitcNo. 549tfor dsewage sorlNo. 1862rfor eweTl/pump described. This app and the Rules and Regulations of the�San Joaquin Local Health District. Job Address [ Subdivision Name, _Phone ` Owner's Name CLP�� f3 '1 Address Phone !� 't License No. �) Contractor's Name 1 DESTRUCTION -K - TYPE OF WELL/PUMP WORK': nµ NEW-WELL 3'Q� •WELL- REPLACEMENT 17, ' PUMP INSTALLATION >�r SYSTEM REPAIR OTHER LJ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL INTENDED USE TYPF OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Industrial ❑ Open Bottom E]Manteca i Trac Dia. of Well Casing omestic/Private Gravel Pack ❑ y Other E] Delta Type of Casing V Irrigation Approx. E3 Eastern Specifications 1Depth Depth of Grout Seal Cathodic Protection ' Geophysical Type of Grout U Other r Surface Seal Installed by E Type of Pum H.P: :J - State Work Done j Repair Work Done M YP P. _ Sealing Material (top 50') Well Destruction [] Well Diameter_ W Depth ` Filler Material (Below 50') p) . No septic tank or seepage pit permitted if public sewer is N TALLATION El REPAIR/ADDITION J ( -....�.�-avai'lable-with in-200 feet:) TYPE OF SEPTIC WORK: NEW 15 � { Installation will serve: Residence _ Commercial _ Other . Number of bedrooms Lot size Number of living units: Water table depth ,. -Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK F-1 Type/Mfg Capacity Method of Disposal Mf ti Capacity , PKG. TREATMENT PLT. {J TYPe/ 9 - - Property Line SEWAGE SYSTEM F-1 ; I to nearest: Well Fouhdafion DESTRUCTION � Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED Distance to nearest: Well Foundation P h Size Number Dept SEEPAGE PITS ❑ .� SUMPS Property Line Distance to nearest: Well Foundation Pro l�l � DISPOSAL PONDS „i I hereby certify that I have rulesaand this atplicati theand dathat JoaquinwLocalork ,Heall lthdDistrictone in Ccordance with San Joaquin county ordinances, "I certify that in the performance of the work for which this Home owner or licensed agent's signature certifies the following: y ensation laws of California." permit owner issued, I shall not employ any person in such manner as to become subject to workmanS camp 3 Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which ' ersons subject'to workman's compensation laws f California." this permit is issued I spial] emplo The applicant must 1 for all('e inspect ns. omplete draw' on reverse si e• pate: t Signed X k FOR EPARTME U ONLY Area '54 J�, _ +Stk 466-6781 i[f Application Accepted by V Lodi 369-3621 l Additiondl Comments: F Date _ Manteca 823-7104 f Pit or Grout Inspection;by p_ ca_�'3 L Tracy 835-6385 Date 1 Final Inspection by W Applicant - Return all copies t': Environmental ileaVhPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 RECEIVED BY DATE PERMIT N0. EDr- SEAMOUNT DUE AMOUNT REMITTED qF ! '$ �.s 13 10/82 500 EH-j3-24 REV. 10/82 ' 14-26