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r APDL ICATION FO,� PERM; SG,N JOAQ6iN LOCAL HEALTH D;STRICT I 1601 E. HAZELTUN AVE., STOCKTGN, CA PERMIT N0. Telepho'Ae (209) 466-6781 .q PERMIT EXPIRES 1 YEAR FROM DATE ISSI1 C, DATE ISSUED p , (Complete in Triplicate) OPY 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 and the Rules and Regulations of the San Joaouin Local Health District. Job Address k2-& V,1� gs Subdivision Name IS72 — 9 Owner's Name LIUM T-A A3 7V A.) Address "e Phone Contractor's Name 01Z. License No. 42 ).7e- Phone TYPE OF WELL/PUMP WORK: W WELL WELL REPLACEMENT i NEW ❑ � DESTRUCTION ❑ ' PUMP'INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE p� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Industrial ❑ Open Bottom MantecaOia, of Well Excavation ❑ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other Delta F irrigationType of Casing Approx. [] Eastern Cathodic Protection Depth Specifications ❑ Geophysical=-,.- y- Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 1 Sealing Material (top 50') '1 Depth, 1 Filler Material (Below.50') TYPE OF SEPTIC WORK: NEW INSTALLATION — REPAIR/ADDITION LI : (No septic tank or seepage pit permitted if public sewer is CyS Installation will serve: Residence ;<'.1 ommercial Other available within 200 feet,) Number of living units: —�— Number of bedrooms. "y Lot size Character of soil to a d pth of 3 feet: 'j Water table depth SEPTIC TANK to Capacity No. Compartments PKG, TREATMENT PLT, Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION F-1 LEACHING LINE No. & Length of lines _ �_^ ]� _ Total length/size _70 fx.> FILTER BED ❑ Distance to nearest: Well: Foundation Property Line I"�! SEEPAGE PITS Depth Size Number SUMPS ❑ 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 Healtli.bistrict. 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 work'man� 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,campensation laws'of California." The applicant must c li fo all required 'nspeEtions,, Complete drawing on reverse side, I Signed X Title: Date: F0 DEPARTMENT SE ONLY f Application Accepted by cArea [] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date--<Z. ❑ Tracy 835.6385 Applicant Return all copies Environmental Neo h Permit/Services 1601 E. H elton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO OLS V3 73 EH 13-24 REV. 10/82 10/82 500 14-26