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APPLICATION FOR,PERMIT; SAN JOAQUitd LOCAL HEALTH DISTRICT rI 1601 E. HAZELTON AVE., STUCKTON, CA PERMIT NO. S"T Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED DATE ISSUED r T(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 Dis t. Job Address u ivzs on Name / f 0910 Z Owner's Name G Address Phone Contractor's NameIY� �� Phon License No. � �nr 2,1 a TYPE OF WELL/PUMP WORK: NEWtWELL WELL REPLACEMENT 1�� �' � DESTRUCTION U ed1..G. PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U Ybb-2v3ye 7j DISTANCE TO NEAREST: SEPTIC TANK n A/0 1A �— SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION y AGRICULTURE WELL OTHER WELL h /YqvNN' � PITS/SUMPS I'Ni�OED USE ;1 , TYPE:OF WELL PROBLEM AREA � CONSTRUCTION SPECIfi[CRTI0N5 ❑ Industrial Open Bottom U P ❑ Manteca. Dia. of Well Excavation 4 iJ Domes t c/Private Gravel Pack Tracy fr. # Dia. of Well Casing, ' Public', Other Del to f Irri ation 1 1� ' Type of Casing � - �-j g �_O_DCT Approx. [] Eastern - ❑ C thodic Protection Depth Specifications Geophysical i i Depth of Groutr'Seal � 1 Other 6aoUND wgVC2 Movilokilvi G Type of Grout Surface Seal Installedv6y Repair Work Done D Type of Pump. &a.Nix-- H.P. State Work Dane i''" Well Destruction U Well Diameter) Sealing Material (top 501) f n ! Depth Filler Material (Below 50'} 1 _i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is i ' available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: ?Number of bedrooms Lot size `nom Character of soil to a depth of 3' feet: Water table depth SEPTIC TANKType/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. Type/Mfg Capacity Method of D `s'posal SEWAGE SYSTEM Distance �to nearest: Well Foundation Property;tl-ne � DESTRUCTION ❑ I LEACHING LINE U No. & Length of lines Total length/size ;w F FILTER BED Distance to nearest: Well Foundation k 'Property Line-!" SEEPAGE PITS ❑. Depth Size Number Oe r SUMPS U Distance to nearest: Well FoundationProperty Line , DISPOSAL PONDS ', I hereby certify thatel 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:'. 5 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; Irshall not employ any person in such manner as to became subject to wvrkmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify'that in the performance of the work for which this permit is issued, I shall employ persons subject to,workman`s compensation laws of California." The app] ' ant m st'cail for a14 required inspections./Complete drawing on,reverse side. Signed X Title: Date: �_ �a,_ R DEPARTMENT USE-ONLY, q Application Accepted by i ,�,, Area� -1 Stk 466-6781 y T Additional Comments: f Lodi 369-3621 �\ Pit or Grout Inspection by lr Date ❑ Manteca 823-7104 Final Inspection by _ e i' r Date Tracy 835-6385 Applicant Return all copies to: eZvironmenta,1,Health Permit/Services 1601 E. Hazelton Ave., P.0• Box 2009, Stk., CA 95201 FEEESr 645E AMOUNT; DUE--" AMOUNT REM[TTED't{ RECEIVED BY DATE PERMIT N0. i INFO e 14 FH 13-24 REV. 10/82 Xr 10/82 500 14-26