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APPLICATION FOR PERMI <br />SF.N JOAQt;iN LOCAL '>sF�.LTH DISTRICT <br />1601 E. HAZELTON AVE., STUCKTON, CA 1'J` �;dil ERMIT NO. <br />�: <br />Telephone {209) 466-6781 SA IV J } DATE ISSUED la <br />PERMIT-EXPIRES 1-YEAR FROM DATE ISMA.�QU11V L <br />(Complete in Triplicate) J� '�}I'7�''1� <br />App3ication is hereby made to the San Joaquin Local Health District for a permit to construct and, or install the work herein <br />described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No.. 1862 for well/pump <br />and the Rules and Regulations of the San Joaquin Local Health-District. <br />�� ��� �` a Subdivision Name <br />Job Address —F� — , rL ' Phone <br />a. Address <br />Owner's Name Phone <br />Contractor's Name ° icense No. <br />_ - M <br />TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br />PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br />�SEWER LINES / DISPOSAL FLD. / PROP. LINE <br />DISTANCE TO 'NEAREST: SEPTIC TANK /' PITS/SUMPS <br />FOUNDATION 1 AGRICULTURE WELLOTHER WELL I <br />i <br />INTENDED USE TYPE DO WELL PROBLEM AREA �aCONSTRUCTI-'ION SPECIFiICCATION5 <br />• = Dia. of Well Excavation�2�'6 <br />' - 0 Industrial Open Bottom Manteca — <br />15rlDomestic/Private Gravel'Pack [J Tracy Dia. of Well Casing <br />0 Public Cf Other:. Delta- Type of Casing A� -. 7 <br />V Irrigation Approx. 0 Eastern Specifications _70 <br />Cathodic Protection Depth Depth of Grout Seal <br />Type of Grout <br />Geophysical <br />CJOther Surface Seal Installed by r <br />Type of Pum H.P. State Work Done <br />Repair Work Done ❑ p <br />Well Destruction LJ Well Diameter,1 Sealing Material (top 501 <br />Depth 'i Filler Material {Below 50') -- C <br />3 <br />d if <br />TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ ADDITION LJ (No septic tank or seepage p�availableewithrnu200cfeetsewer �s <br />Installation will serve: Residence _ Commercial Other <br />Number of living units: Number of bedrooms Lot size <br />Water table depth <br />Character of sail to a depth of 3 feet: aCompartments <br />SEPTIC TANK [_j Type/Mfg Capacity <br />Capacity Method of Disposal <br />PKG. TREATMENT PLT. [] Type/Mfg Property Line <br />SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation <br />DESTRUCTION <br />No: & Length of lines Total length size <br />LEACHING LINE LJ g Property Line <br />est: Well Foundation <br />Distance to near <br />FILTER BED <br />•,�-"'Sizer_,_mber <br />SEEPAGE PITS [� Depth <br />'Foundation Property Line <br />SUMPS LI Distance to nearest: Well <br />F <br />DISPOSAL PONOS <br />I hereby certify that I have prepared this application and that the work will 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 9n the performance of the work for which this <br />permit'is issued, I shall not <br />ntraloy ctinansignaturelcertifiesn such nthe follow ngner as to �meIscertifyubject tthat rinathe cperformance ofompensation wthe fwork �for nwhich <br />Contractor's hiring or sub-contracting <br />this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />The applicant s call for a re inspections. Complete drawi on reverse s e• ,^ Date: Y <br />Signed X �UOULY <br />OR DEP MENT Stk 456-6781 <br />Area <br />Application Accepted by fi✓ J.Lodi 369-3621 <br />+ Additional Comments: �G— <br />���' Y � Manteca'823-7104 <br />Fsr Pit or Grout Inspection by Date Tracy 'a, 535-5385 <br />date - ____ <br />Final inspection by <br />Applicant - Return all copies to:, Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk•, CA 952 1 <br />4r DATEPERMIT NO. <br />, <br />FEE BASE ry AMOUNT .`DUE AMOUNT REMITTED RECEIVED BY , <br />INFO' �� $ —\,..3- L13 1d <br />10/82 500 <br />4 j <br />LH 13-24 REV. 10/82 <br />14-26 <br />