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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ��q Telephone (209) 466-6781 DATE ISSUED l PERMIT EXPIRES I YEAR FROM DATE ISSUED CU V ci-vft&;, (Complete in Triplicate) Application is 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 9801 Moffat Blvd. Manteca Subdivision Name _ nZa Owner's Name Beall Trans-Liner Address 9801 Moffat Blvd.. Manteca Phone 823-7129 Contractor's Name Manteca Plumbing QQanse No. 186808 Phone 823-2423 TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT F� DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER [� 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE —• FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private [] Gravel Pack [] Tracy Dia. of Well Casing ❑ Public F-1 Other ❑ Delta L1 Irrigation Approx. ❑ Eastern Type of Casing [�Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal Type of Grout (Other Surface Seal Installed by Repair Work Done EJ- Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') d Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION 1J (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units: 0 Number of bedrooms 0 Lot size 2 . 8 1 Character of soil to a depth of 3 feet: sandy loam Water table depth 12 � SEPTIC TANK Type/Mfg existing,, tank Capacity200_ 0 sal No. Compartments 2 PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No., & Length of lines J1W-- Total length/size r FILTER BED [J Distance to nearest: Well 100 Foundation fi2 1 Property Line 5 ••_,_ SEEPAGE PITS rl Depth Size !Number SUMPS IJ Distance to nearest: Well Foundation Property Line 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, I shall not employ any person in such manner as to become subject to workman§ compensation laws of California." Contractor's hiring or sub-contract�Ing signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I all emp-1i,6gE rsons subject to workman's compensation laws of California." The applic lly, fo /a � f inspections. Complete drawing on reverse side. Signed X I Title: Owner Date: 1/27/84 JgR DEPARTMENT USE ONLY Application Acceptei by Area ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection byDate Tracy 835-6385 : En Applicant - Return all copi tovironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. D INFO JJ ^�p vg � r � EH 13-24 REV. 10/82 10/82 500 14-26 l