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if 71 i � APPLICATION FOR PERMIT ' �1Jj SAN JORQU;!! LOCAL HEALTH Rb R�CT --ry1601 E. HAZELTON AVE., STOI , CA Et rtl� �9 PERMIT NO. Telephone (209) 466-6781 'r" •• !Lv .r3/3 L�3 PERMIT EXPIRES 1 YEAR FROM DATE.h0�},FyD DATE ISSUED°� '(Pl!'�1 .97 C) /� T2{ / ,Q /j (Complete in Triplicate) per i }�{f'iail � /" g • Lf_ IJ GSI.'Ldl�`�.S.r'i6i?d �:."�La� -�1�, �j 9r.—��Q•—QI 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. 1862 for well/pump o4 and the Rules and Regulations�of the an Joaquin Local Health District. Job Addres Owner's Name A dress Phone r Contractor's NameCorp, License No. Phone q_ f TYPE OF WELL/PUMP WORK: NEW WELL W L REPLACEMENT 71 DESTRUCTION PUMP INSTALLATION [] AWREPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 1d ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( industrial U Open Bottom F_�Manteca Dia. of Well Excavation - ❑ Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing 17 Public ❑ Other ❑ Delta Type of Casing ` Irrigation Approx. E] Eastern Specifications ❑ Cathodic Protection Depth ^ Depth of Grout Seal Geophysical Type of Grout 1 Other Surface Seal Installed by fl Repair Work Dane Type of PumpH.P. State Work Done ,;, Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D (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: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth I^� SEPTIC TANK Cj Type/Mfg Capacity No. Compartments r y� PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal (V SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS L 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, 1 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 i this permit is issued, I shall employ persons subject to workman's compensation laws of California." The appli nt must c 11 or 11 required inspections. Complete drawing on rever a side. Signed X Title: — Date: 7 NT l ONLY Application Accepted Area [� ';Z- Stk 466-6781 Additional Comments Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ic� �i>'� Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT R€MITTED RECEIVED BY DATE PERMIT N0. INFO �'s 3--Lt�-+ I EH 13-24 REV. 10/82 10/82 500 14-26