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r APPLICATION FOR PERMIT D SAN JOAQbih LOCAL HEALTH DI V 1601 E. HAZELTON AVE., STCCKTON, C+' 4. 1987 4Q 7 PERMIT N0. Telephone (209) 466-6781 , [ UU 11 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DAT MENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 d c>b -Name Owner's Name -4/,44415C jea e Contractor's Name C&&MMe 40_41�icense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION f- ....P-UMP -INSTALLATION F7SYSTEM REPAIR ❑ OTHER ❑ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial F-1 OpenBottom 71Manteca Dia. of Well Excavation j❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing _ -❑ Public ❑ Other ❑ pelta A Al Type of Casing L i Irrigation :Approx. ❑ Eastern EDe th Specifications F-1CathodicProtection p Depth of Grout Seal 1-1 Geophysical Type of Grout Other ► .,,,�-.� Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction Well'Diameter --- ------ Sealing Material (top 50') _ DepthQ �`, Filler Material-(Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No se�ti.c 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 ter table depth Character of soil to a depth of 3 feet: Wa �s SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line ' DESTRUCTION LEACHING LINE ❑ No, & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation Property Line, s SEEPAGE PITS ❑ Depth size Number ! �( SUMPS ❑ Distance to nearest: Well Foundation ) Property Lin �? 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 tin 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 workmarK compensation laws of California." Contractor's hiring or sub-contracting siglhature certifies the following: I certify-that'IrT-the"performance of the work for which this permit is issued, I hall employ persons subject to workman's compensation laws of California." The applicant st 11 or all uired inspections. Complete drawing on reverse side. Signed X - Title: Date: DEPARTMEN USE PNLY lfi� Application Accepted by Area � ❑ Stk 466-6781 Additional Comments: Aoi �' �Y/�/ c. 4.it�r"5 f ❑ Lodi 369-3621 Pit or Grout Inspection by Date � ❑ Manteca 823-7104 � Final Inspection by Date l o O L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Heal Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY D00-- 01ATE PERMIT NO. INFO 71 EH 13-24" REV. 10/82 10/82 500 14-26