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I APPLICATION FOR PERMiT SAN JOAQU,I; LOCAL U� ALTH- D1S �}('� { 1601 E. HAZELTON AVE., STOCKTO �+ l B3 4� Telephone .(209) 466-678I V� PERMIT NO. 7.3 PERMIT EXPIRES 1 YEAR FROM DA- ISSUED �, -tuorPI 'DATE ISSUED f 0 — /^ (Complete.in Triplicate) SAN Application is hereby made to the San'Joa uin Local HVOL 6� q ealth District for a permitto construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or Noy 1862 for well/pump and the Rules and Re ulations of San Joaquin Local Health District, I; Job Address , NJ Subdivis' Name 4}j� Owner's Name Y1 � 1'� Phone Contractor's Name c License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTIONIt PUMP INSTALLATION SYSTEM REPAIR OTHER 6 D G}} &C DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLO. PROP. LIfNE OL�'/v C4. r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom E]Manteca Dia, of Well Excavation Domestic/Private [—] Gravel' Pack Tracy 0iaa of"well 'Casing L7 Public EJ Other l Del to 11 1 L IrrigationType of Casing ] Approx. � Eastern Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal �} 1 Other Type of Grout t Surface-Seal Installed by7 ;( s. Repai`r Work Dong- ,•Type of Pump•y H.P. ` `I ' S _f'5tate Work 1Done air/ C (/^ .► lJe]l Dest'r" ion j Wel- _D ameter- k,—Sealing Material; (top;So' j; Depth t :•Fi,l4er.,Materia7l'(Below 50')_ ? �. r�, TYPE OF SEPTIC•.WORK,:. NEW INSTALLATION U REPAIR/ADDITIDhI?= 's,(No..se. tic tank''o-r see t•J 1 441 1 U_. 0 P; , F . page pit :permitted i f public sewer i s �j In� available within 200 feet.)allation will serve: Residence � Commercial _ Other a Number`bfxl:ivin9 units Number of bedrooms Lot size Character of soil to_a depth of 3 feet: Water table depth SEPTIC TANK E] _ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. -Type/Mfg !— .•pacit�.- ❑ ., Capacity Method of Disposallk SEWAGE DE SYSTEM Distance to nearest: Well -'`JFoundatio6 � ' , -'' 'Pro ert ?Line !i DESTRUCTION ❑ C �'.. r �.,,,� P Y 1. � LEACHING LINE jJ No. & Length of lines Total length/size I FILTER BED 71 Distance to nearest: Well Foundation Property5Line !G SEEPAGE PITS ❑ Depth Size Number ? I� E SUMPS L Distance to nearest;. .Well FoundationProperty.`Line DISPOSAL PONDS f �� I herebycertify that I have f Y 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. iI i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit Js issued, I shall not employ any persohjin 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 , d this permit is issued, I shall employ personsisubject to workman's compensation laws of California." 1 The appiica ust call for all equi a inspections. Complete drawl n reverse side. Signed K i Title: Date: FOR DEP TM USE ONLY Application Accepted by. 'ILa i. Area ] 5tk 466-}6781 Additional Comments: : \ I 4 .. EJi 369-3621 Pit or Grout Inspection ` 3 J-DateManteca 823-`!7104 Final Inspection by Date Q fi/ 0 Tracy 835i63B5 Applicant - Return all 'copies to: Environmenta- , ealth 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 EH 13124 REV, 10/82 110/82 500 14-26