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APPLICATION FOR PER 'ATI ? SAN dOAQUI`. AVE.,LOCAL HE-,LTH DISTRICT ZELTON STOC 1601 E. HATON CA PERM N0.Telephone (209) 466-5783 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED -7—( tj (Complete in Triplicate) F 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 Joaquin Local Health District. Job Address Subdivision Name Owner's Name - Address Phone Contractor's Name Z, License No. Phone ��'. �'Z/ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER [J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNORTiON AGRICULTURE WELL OTHER WELL PITS/SUMPS 1� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS vI I J Industrial U Open Bottom Manteca Dia, of Well Excavation T1 Domestic/Private v U Gravel Pack Tracy Dia. of Well Casing Public ❑ Other Delta r �jIrrigation Approx. ❑ Eastern Type of Casing Depth Specifications De N Cathodic Protection P 11 Geophysical Depth of Grout Sealj U Other Type of Grout Surface Seal Installed by Repair Work Done F] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ; Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION �y� REPAIR/,ADDITION U {No septic tank or seepage pit permitted if public sewer is F, Installation will serve: Residence _✓ available within 200 feet.)Commercial _ Other ` Number of living units: Number of bedrooms f T Lot size Character of soil to a depth of 3 feet: CAA K Water table depth SEPTIC TANK Type/Mfg � L, �� Capacity J�*p No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation /�` Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines / —S"� 7otaT length/size S ! FILTER SED ❑ Distance to nearest: Well Foundation 1j ' Property Line s SEEPAGE PITS r;;r, Depth 2x Size (s+ Er Number SUMPS Distance to nearest: Well [O( 4' Fa un dation _ ��j�! Property Line /[1 i 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, I shall not employ any person in such manner as to became 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 is issued, I shall employ persons subject to workman's compensation laws of California." The applicyt must call f al.l .required spections_ Complete drawing on reverse side. F1Signed X,� Title: Date: 1Y DE AI$TMENjUSE ONLY Application Accepted by Area _ �. ' [] 5tk 466-67$1 FAdditional Comments: / [] Lodi 369-3621 Pit or Grout Inspection by Date //i / Manteca 823-7104 Final Inspection by t Date L Tracy 835--6385 Applicant - Return all copies to: Environment4l Health Permit/Services 1601 E Hazelt6n Ave., P.O. Box 2009, Stk., CA 95201 4 f, FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO RFs C� ��- W-W Eli 13-24 REV. 10/82 10/82 500 14-26 P N