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- M APPLICATION FOR PERMIT .i -- SAMJOAQCi?d LOCAL 'ri rLT' DISTRICT' � 1501 E. HAZELTON AVE., STOCKT,ON, CA PERMIT N0. Telephone .(?09) 466-6781 _+ DATE ISSUED i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete.in Triplicate) A r Application is hereby made to the San Joaquin Local Health District folr a permit'to construct an 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 j and the Rules and.Regulations of the San Joaquin Local Health District:. 0 ti ,fob Address 2-8 Subdivision Name 3 �I � C Phone a Owner's Name Address I i- -0, Contractor's Name hY1r►.�.�4 L►C� ��1rtiSnlM►� License No. Phone TYPE OF WELL/PUMP WORiG:� NEW WELL WELL REPLACEMENT 0 DE57RUCTION _ .-.� 'OTHER-^LJ �'r'""PUMP"INSTALL"ATI,ON"r�•""°'"'SYSTEM w DISPOSAL FLD, PROP, LINE DISTANCE To NEAREST: SEPTIC TANK SEWER LINES OTHER WELL ;P,ITS/'SUMP$ FOUNDATION AGRICULTURE WELL �_� ; s INTENDED USE TYPE OF WELL B .QROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom.. Manteca IT Dia. of Well Excavation f � U �� ' +> U Domestic/Private (] Gravel Pack Tracy I Dia. of Well Casing i' Public Other Delta Type of Casing Eastern j$ OQ V Irrigation Approx. Specifications Cathodic Protection Depth Depth of Grout Seal T 1 Geophysical �-• Type of Gi^'out Other j � 'Surface Se81 installed by � � / �;_,�.,.,,.,,,....-.w•-,-,..-.-;....moi Repair Work Done ElType of Pump .P• J 1� State Work Done nfl Sealing Material } _ t FI Well Diameter g t(top 50' Well Destruction Depth Filler Material (Be1.s6w�ys5Y0' a i 6 TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION �A (No septic tank or seepage' pit permitted if public sewer is ova"ila5lewitfiin'2D0feet.) 1 Installation will serve: Residence _ Commercial Other ( fit' Number of bedrooms Lot size _ __� r / Number of living units: j; Water table depth 3J C ' Character of soil to a 'depth of 3 feet: No. Compartments c Capacity '' _� ". SEPTIC TANK F_[ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Capacity SEWAGE.SYSTEM Distance to nearest: Well Foundation Property Line i DESTRUCTION ' M-;., Total length/size LEACHING LINE Lj No. & Length of lines FILTER BED Distance to nearest: Well Line Foundation Property Size �} ��;=i Number , SEEPAGE PITS Depth �� -* -= - i Foundation ) Property°Line JrO SUMPS L1 Distance to nearest: Well V I DISPOSAL PONDS CI ' in e with San Joaquin county vF � I hereby certify that I have prepared this application andjthat'the wcM,will--!6e doneaccomance of rdanc ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the suchfmannernas to become subjectthat ntohworkmank cerfor ompensaance of the California." permit is issued, I shall not employ any p "I certif. -that in the performance of the work for which k Contractor's hiring or sub-contracting signature certifies the following: ys this permit is issued, sI shall employ persons subject to workman's, compensatiori laws of California.' p The applicant must calf,for all required inspections, Complete drawing on-reverse side. Date: Signed X ��WGYdI Title: �Lvy,''✓ F R PARTMENTr E ONLY s .r1. Stk 466-6781 I! Area �� Application Accepted by t ; Lodi 369-3621 A itionaI Comments: f Date Montero 823-7104 Pit r Grout Inspection by Date Tracy 835-6385 /�7/ L final Inspection by Replicant - Return all copies to: Envir ental Health Permit/Se, vices 1601 E, Hazelton ve., P.O. Box 2009, Stk., CA 95 Y RECEIVED BY DATE PERMIT,.NO. EINFO ErH AMOUNT DUE AMOUNT REMITTED - 0 10/82 500 Eh 13-24 REV. 10/82 14-26 f it