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` 2 V APPLICATION FOR PERMIT SAN JOAQU(H LOCAL HEALTH DIS I q �{1p q -7 1601 E. HAZELTON AVE., STOCKT N, CA SEP 1 2 1%3 PERMIT NO. (J 3'L/ Telephone'_(209) 466-6781 DATE ISSUED 3 Z l.. PERMIT EXPIRES I YEAR FROM DATE ISSO ..q 1...-)A USPV LOCAL, (Complete in Triplicate) N LTH DISTRICT Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein 6. 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 ]�' F. r��rG2 �>� n•mrcSubdivision Name Owner's Namess Phone g3)- d V b' Contractor's Name _ n.. License No. :an-f'RaIg Phone ryrej TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial (J Open Bottom EJ Manteca Dia. of Well Excavation J LJ Domestic/Private F-1 Gravel Pack 0 Tracy Dia. of Well Casing 1-1 Public E—j Other 0 Delta Type of Casing Lj Irrigation Approx. EJ Eastern EJ Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal Type of Grout im U Other Surface Seal Installed by L Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material (top 50') �J Depth Filler Material (Below 50') d TYPE OF SEPTIC WORK: NEW INSTALLATION FvREPAIR/ADDITION J (No septic tankseepage pit permitted if public sewer is f JJ ,r�T ��S&F availp��e wiyh�n 200 feet.) L Installation will serve: Residence _ Commercial ✓ Other �i M1(J.t Number of living units: AEA-N-mber of bedrooms Lot size Character of soil to a depth of 3 feet: w Water table depth LSEPTIC TANK v� Type/Mfg -p ' C Capacity ^ C No- Compartments ' PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Ei Distance to nearest: Well + Foundation Property Line Zno . + I �- ( DESTRUCTION L+ LEACHING LINE L—aj` No. d Length of lines 7 - j OQ'. Total length/size Z� FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS Q Depth Z5 Size 31C, Number 2- 6. V SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county r 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 become subject to workmanls compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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." r The applicant ust call for 11 equirgd inspections. Complete drawing on /rp�Ver�/e i Signed % �!?rlsv'.--f- Title: !�i-F 7'S'At4H' Date: y-�- X 7 ARTMEftT E ONLY V, Application Accepted by Area tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 V Final Inspection by /il/ Date �� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health P 1t/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk_, CA 95201 I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY pATE93- Eli PERMIT NO. Ifr INFO X45 �t`t31 L13-24. REV. 10/82 10182 500 IL. 14-26