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i APP LICA_T10,N FO.; PE .... S[;. J0A.QL;,. LCC_ HE.-.L 1H I R I C T �y 1661 E. HA'_ELT01+ AVE STOCTO A PERMIT N0. a � F Telephone (209) 466-672J n DATE ISSUED(�_ -7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicaee) ► + 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 Ordina ce No. 54J for sewage or No, 1862 for well/pump andthe Rule and Regulations of.tthe San Joaquin Local Health District. $ Job Addre II + t ; ! /+'/ i5 I Subdivision Nafne-- Owner's Name ——, �`� Phone ; Contractor's Nal;t 7- moi- License No. ,_9-7/ Phone j FTYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT L DESTRUCTION L QA PUMP INSTALLATION (( SYSTEM REPAIR L OTHER L F" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i ' FOUNDATION AGRICULTURE 14ELLOTHER WELL PITS/SUMPS � l INTENDED USE TY,d OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tl` I IndustrialX� L Open Bottom � Manteca Dia. of Well Excavation F �mestic/Private, L Gravel Pack Tracy Dia. of Well Casing L� PublicOther Delta LIrrigation -_� Approx. ❑ Eastern Type of Casing Depth Specifications De Cathodic Protection P Geophysical Depth of Grout Seal L Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump �- H.P. Z;_ State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,4DDITION ID (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 01 Character of soil to a depth o, 3 feet: Water table depth SEPTIC TANK U Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal p SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line 4 DESTRUCTION LEACHING LINE L No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line _c,., SEEPAGE PITS ❑ Depth .� Size Number SUMPS �� Distant-e to nearest: Well Foundation Property Line DISPOSAL PONDS I k 1 3I 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 followirg: "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 hecome subject to workmanIs 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 ,issued, I shall employ person subject to workman's compensation laws of California. The applic t must call for all 'eq fired i pections. Complete dr Ing on reverse side. Signed Title: Date: �l R DEPARTM Application Accepted by rea Q Stk 466-6781 Additional Comments: — ❑—Lodi 369-3621 Pit or Grout Inspection by Date L Manteca 823-7104 Final Inspection by Z_/ } r tit, ,a. f y Date !! f t' Tracy 835-6385 Applicant - Return all copies toil Environmental Health/°ermit/Services 1601 E. 'Hazelton Ave., P.O. Box 2009, Stk., CA 95201. I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NC. � I INFO EH 13-24 REV. 10/82 1 10/82 500 14-26 ;I I