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F APPLICATION FOR PERMIT SAN JOAQU'iN LOCAL HEALTHP.7- Us IL 261 16GY E. HAZE.LTON AVE., STO , CA PERMIT NO. Telephone (209) 466- (� 1 2e73198 !� 4 :7J DATE ISSUED SJRy�3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - T (Complete in Triplicate) SAN 40 QU?N LOCAL Application is hereby made to the San Joaquin Local Health District for a WEAU--MorMTRn Tr install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. .: Jab Address �3�i1; .IA/_. ..�/!pLr�Q 12U• Subdivision Name L(fj of DreoVAR..,Crs;�TIJ' 1 Owner's Name _ Q� S' pr, _ _ _ Address ( )V��VJpu � j�.� Phone21?'�,4/Q'pFj Contractor's Name [A(,LV1D&1ky& (' 0 W41.j e No. Tic' j2 T� Phone TYPE OF WELL/PUMP 14ORK: NEW WELL WELL REPLACEMENT F-1 DESTRUCTION ❑ Q PUMP INSTALLATION SYSTEM REPAIR OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK ijo,) jPT, SEWER LINES DISPOSAL FLD. PROP. LINE CT FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS OpenlBottom -:D..Manteca-. Dia.—of—Wel-1 Excavation__—,.J1', Domestic/Private XGrav6l Pack Tracy Dia. of Well Casing Public ❑ Other Del to Type of Casing PUL ga PSI. Li Irrigation Approx. Eastern F—ICathodic Protection Depth Specifications ! °Depth of Grout Seal Geophysical [ Type of Grout $SEA/T!?A�LTC LJ Other Surface Seal Installed by �4 Repair Work Done LJ _Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ! available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: I Number of bedrooms Lot size Character of soil to a depth of;3 feet: Water table depth . n SEPTIC TANK L Type/Mfg Capacity No. Compartments l?'Q PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal L SEWAGE SYSTEM . ❑ Distance to nearest; Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line —t-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 workmanls 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 m t 11 fo all required_inspections. Complete drawing on reverse side. Signed X Title: Date: I RTMEN E ONLY Application Accepted b Area �'] Lf Stk 466-6 1 Additional Comments: % [] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by ------16 Date`s racy 835-6385 Applicant . Return all copies to;I Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE 'AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Z{3. m o C EH 13-24 REV. 10/82 _ 10/82 500 14-26