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f'd J Z11, 11Y "T•;1�f l� �a �J r 7 APPLICATION FOR PERMIT �� ` ��1 0• QL Hl l .41ft1 r,,,1,[ r " 1 E�A�AZELTONAAVE�,LSTOCKTONTH �CC �- PERMIT NO. BAR I - ,983 , Telephone (209) 466-6781 DATE ISSUED % 7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQ PRI LOCAL (Complete in Triplicate) HE&TH DiSTMUT 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 IS63,for well/Pump and the Rules and Regulations oflthe San loaauin Local health Di L�� •B��`O r -�j D 1 i Job Address IHSS hov5e- T � Te le r 2� SUbdlvi e i� _ r? �- hone Address -�i Owner's Name Phone Contractor's Name License No. i4 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT �� DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ I SEWER LINES DISPOSAL FLD. PROP. LINE j DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS_ - --'•¢ FOUNDATION �" AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial [J- Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private Gravel Pack M Tracy Dia. of Well Casing Public Other Delta Type of Casing Li irrigation Approx. E]Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal t Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done N Type of Pump _ H•P• �'� �- State Work Done Well Destruction U Well Diameter Sealing Material (top 50') a Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION J (No septic tank or seepage pit permitted if pablic sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other fh Number of living units: Number of bedrooms Lot size Water table depth Character of soil to a depth of 3 feet: Z SEPTIC TANK F-1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [� Type/Mfg Capacity Method of Disposal ,��.. SfWAGE-.SY--STEM. Distance to nearest:_Well Foundation Property Lie".. F' DESTRUCTION W ze LEACHING LINE U No. & Length of lines Total length/Pro FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line f {J ` DISPOSAL PONDS ❑ 1(��1j I' k 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. G Home owner or licensed agent's signature certifies the sation laws of California." Following: "I certify that in the per of the work far which this G permit is issued, I shall not employ any person in such manner as to become subject to workman compen 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 applic ust call for all required inspections. Complete drawing on reverse side. Date: Signed Title: DEPARTMENT USE ONLY Area .Stk 466-6781 Application Accepted by a Lodi 369-3621 Additional Comments: Manteca 823-7104 Pit or Grout Inspection by Date I _ Date 7 $-3 L7 Tracy 835-5385 I Final Inspection by J_ Applicant - Return all copies to- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20D9, St k., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI3 NO. F INFO L 3 1�1 0� �3 <A 10182 500 EH 13-24 REV. 10/82 14-26 4