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?= APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRIGT '�`.I , 1! 1601 ETelephoneON(209) 466-678�N ! �" � PPERMIT NO. AL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C)CE ISSUED !J� (Complete in Triplicate) ,114 ` ► ��' ,ApplicILion is hereby made to the San Joaquin Local Health District for a permit to'con ttrructt and/or install the work herein ,:3<`described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump =,aild.the'Rules and Regulations of the San Joaquin Local Health District. �ob RddresS� , c� i d ivision Name Owner's Name essFVC Phone ._ �tC9 Contractor's Nam < $ :C'S S e_,e J jcense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION f Q PUMP INSTALLATION SYSTEM REPAIR_' OTHER lv2 A DISTANCE IO NEAREST: SEPTIC TANK SEWER LINES t� DISPOSAL FLD• PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J U Open-'Bottom— 0 Manteca Dia. of Wei'1•fxca"vation Q - ..� ;".�.,..• .�� 4..* .,,KDomesfic/Private NQ Gravel Pack ❑ Tracy Dia, of Well Casing 'le el b,Vublic ❑Other ❑ Delta } Type of Casing 1 ao Ljirrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical C3 3 U Other Type of Grout • ! ------ � t - Surface Seal Installed by(n e p j Repair Work Done ❑ Type of Pump 5 � - H.P. f State Work Done } Well Destruction U Well Diameter Sealing Material (top 50`) ! Depth i(4o Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) ,,o'Installation will serve: Residence _ Commercial Other Number of'1 iving units: Number of bedrooms Lot size 4, Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK U Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal t SEWAGE SYSTEM Distance to nearest: Well *`Foundation Property Line O� DESTRUCTION ❑ i ft LEACHING LINE jJ No. & Length of lines =- 1 Total length/size ' FILTER BED Distance to nearest: Well Foundation Property Line „ SEEPAGE"PITS �. _Depth Size Number p =-. . _ SUMPS LJ Distance 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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, I shall not employ any person in such manner as to become subject to workman 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 applicant must cal r all requ' ed inspections. Complete drawing on reverse side. "19 Signed X Title: _ _ Date: MENT/LIS N Application Accepted by FOR D �{ Area Stk 466-6781 Additional Comments: QLodi 369-3521 Pit or rou Inspection by Date E Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Env r amental Health Permit/Services 1601 E. HazeltondA'4e„ P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO g S r W EH 13-24 REV. 10/82 10182 600 P 14-26 CA