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r G APPLICATION FOR'PERMIT" SAN JOAQUIN LOCAL HEALTH, DISTRICT F 1601 ETelephoneN(209)'46606780N, CA .; PERMIT N0. F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (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 / fa �p Subdivision Name {� Owner's Name "Ad�yeSs J f Phone 3 _3.2 1O Contractor's Name q0 A �g ' LICEnI, No. 47 f g`+" Phone TYPE OF WELL%PUMP WORK: NEW WEWELL REPLACEMENT Q DESTRUCTION ❑ Oa 4. Aeftr PUMP INSTALLA SYSTEM REPAIR Elr OTHER E]DISTANCE TO NEAREST: SEPTIC TANK 1 D O SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION : AGRICULTURE WELL _ OTHER WELL PITS/SUMPS y� INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria] Manteca Dia. of Well Open Bottom ❑ Excavation Domestic/Private ❑ Gravel Packn ❑Tracy Dia, of Wel] Casing ❑"Pub]is ❑j Other ❑ Delta J Irrigation -- Typemof Casting-^- -. --r •Approx. Eastern a 1 ❑Cathodic Protection Depth _ _ Specifications Geophysical Depth of Grout Seal- ❑Other �. Typetof=Grout ry c Surface Seal Installed by ft,6 g .4/ Repair Work Done ❑ Type of Pump uH.P. Q , State Work Done Well Destruction Well Diameter i ❑ Sealing Material {tap 50'} Depth Filler Material. {Below 501_} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ _REPAIR/ADDITIONL.1 (No septic tank or'seepage y pit permitted if public sewerjis +� Installation will serve: Residence Commercial `'Other. f available within 200 feet.)[ Number of living units: Number'o"f.bedro s . ,` _ Lat size � Character of soil to a depth of 3 feet; ' ' E'P" Water table depth 1 SEPTIC TANK ❑j Type/Mfg 7 '` rapacity No. Compartments " "'� ~ PKC, TREATMENT PLT. E] ` Type/Mfg Capacity Method of Disposal ., SEWAGE SYSTEM Distance to nearest:_Well w� , ' Foundation Property Line DESTRUCTION'w ❑ t LEACHING LINE `f ❑ 1 No. & Length of,lines Total length/size `,. FILTER BED ❑ ", Distance to nearest: Well Foundation Property Line SEEPAGE PITS r Dii Depth Size Number SUMPS { Distance —ter 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 ,y- C ordinances, state laws, :and rules and,regulations of the San Joaquin Local Health District, _ 1 }f Home owner or licensed agent's signature certifies the following, tI certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner ai-to become subject to workman$compensation laws of Cal-ifornia:"�t Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance o�the work for which this permit is issued, I shall employ persons subject to workman's 6;pensation laws of California." The applicant must c 11 'for all required inspections. Complete rawing on reverse side, i Signed X j Title: TE 71=A Oi1�TJ2 L°Tvlbate: D ARTMENT USE ONLY _ Application Accepted by Area �°} r ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Insp� ection by ��ioM "�""� Date �> L Tracy 835-6385 Applicant - Return ail copie to: He, lth Permit/Services 1601 E. Hazelton AA, P.O. Box 2009, Stk., CA 95201 f —_Ai FEE BASE ,AMOUNT DUE AMOUNT' REMITTED RECEIVED 8Y DATE PERMIT NO. INFO ^�' $ EH 13-24 REV."10/82 `-Li 14-26 10/82 500