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i 4 APPLICATION FOR PERMIT fa=dL IZ.3�7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 .E. HAZELTON AVE_ SIOCKTON, CA PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED ,{ (Complete in Triplicate) PM Application is hereby made to the San Joaquin Locai�Heaith District for a described. This application is made in compliance with San Joaquin County p0 dinan�ecNo$t549tfordsewagesorlNoth1862rforewell and the,Rules and Regulations of the San Joaquin Local Health District, /pump - Job Address 3 ► Subdivision Name Owner's 'Name Z- Address • Contractor's Name Phone License No. Phone t t TYPE OF -ij WELL/PUMP WORK. NEW[WELL Q WELL REPLACEMENT .DESTRUCTION _ PUMP INSTALLATION SYSTEM.REPAIR DISTANCE TO NEAREST: SEPTIC TANKit ��'!" ETHER SEWER LINES DISPOSAL FLD. PROP. LINE ..FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL . v-'PROBLEM AREA r r i" CDNSTRUCTION SPECIFICATIOPdS _ ` Industria] U Open ,Bottomanteca K i;{� ,_.. - -,MDia. of Well Excavation Domestic/Private ❑Gravel Pack, Trac Public � �` � + x � Y Dia, of Well Casing :[J?Otherl. Delta Irrigation Type of Casing _ Apprw-' Eastern a ❑Cathodic Protection Depth ads f Specifications Geophysical Ems, i Depth of Grout Seal 4 Other :`� •.�'ry Type of Grout € 1 f d Surface Seal Installed by I Repair 4 ork Done ,Type of Pump H•p._ti State Work Done Well Destruction (J Well Diameterll Sealing'Material (top 501) Depth it Filler Materi:ai (Below 501) TYPE OF SEPTIC WORk.- NEW INSTRLLATION REPAIR ADDITION U '(-No septic tank or seepage pit permitted if public sewer is Vv +''I ; 4 _ i.i �t available:within 200 feet.) Installation wi'17{serve: Residence ✓ _ Commercial Other i — ,"Number of living units:'---/ Number of bedrooms — Vi Lot size-�7-0)(- i' Character of soil :to a ,depth of 3 feet: S6.TIC,TANKWater table depth P Hype/Mfg Capacity —j�� No, Compartments SG,, TREATMENT PLT. Type/Mfg + Septic' Tank Capacity Method,of Disposal Distance to nearest: Well fi_Foundation Destruction * i �� -.moi Property Line 4+1p i LEACHING LINE j No. & Length of lines ] —' f � ' F DO 'Total length/size /d g Z FILTER 8ED Distance to nearest: Well '� r — to Foundation 2-0 Property Line p j SEEPAGE PITSI4 - r SUMPS # Depth t . Size _ - Plumber ` ¥ }=J Distance lto+nearest'. YWell�.��Foundations.'',` - Pro DISPOSAL PONDS ❑ a --- ---�5 perty-Line *0 �s A ( I hereby certify that .I have prepared this application and that the work will be done in accordance_witli San Joaquin county ' ordinartces;`state laws=and rules and regulations of tfie San�loaquin�Loca1 Health Qistrict. Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not employny person in such manner as to become subject to warkman� compensation laws of California."' Contractor's hiring or sub-contracting signature certifies the following: "1 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 call for all required inspections. Complete dr wi Signed ng on reverse side. X °' Title: Zw2t _ Date: FORrpEPA TMENT USE ONLY Application Accepted by .., , Area _ y C� Additional Comments: R�j — Stk 466-6781 -Lodi 369-3621, Pit or Grout Inspection by t Date f Cl Manteca 823-7104 Final Inspection by Date � .q�c/ Applicant - Return all copies to: Erlironmental Health Permit/Services 1601 E. Hazelton Ave., P.O.TBox y2009355tk�5 CA 95201 FEE BASE AMOUNT DUE- INFO AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. i EH 13-24 REV, 10/82 14-26 10/82 500