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i,YPL.(ATI)N Fin PE PFii; nEALTH JiSTRICT 1601 E. HA2ELTON AVE., STOCkTON, CA PERMIT No, Telephone (209) 466-6781 ,n RATE ISSUEDiCtt�t�_ PERMIT EXPIRES l YEAR FROM GATE ISSUED (Complete in Triplicate) APP!ice tion is hereby made to the San Joaqu In LoCaI Health District for a perm dt to construct and/or ins to 11 the work hertln described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for •.ell/;ur.l and the Rules and/(tegulation5 of the San Joaquin Local Health District. G- Job Address ,_Jr2 dV/O '!j Q4Li_" RD A*71ea0Subdivision Name Owner's Name mac./< /y67R D Address it McLy�r(� D/aZiaMone Contractor's Name Lj. Gy F"r/LLe-Q License No. �,T�r$;,2 Phone . .p // TYPE OF WELQ PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER j❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — ,_ FOUNDATION AGRICULTURE WELL OTHER. WELL PITS/SUMFS iNTENDEU USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 I_J lndustrial U Open Bottom ❑Manteca Dia. of Well Excavation ❑GDmeSt IC/Pr1Vate ❑ Gravel Pack ❑Tracy Dia. of Well Casing ❑Public ❑Other ❑Delta Type of Casing L,j Irrigation Approx. ❑Eastern Specifications n Cathodic Protection Depth Depth of Grout Seal ❑Geophysical — --- U Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 1 State Work Done Well Destruction (_J Well Diameter Sealing Material (top SO') _ Depth Filler Material (Below 50') � i 'TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 9 (No septic tank or seepage pit permitted if public sewer ;s '•� available within 200 feet.! + Installation will serve: Residence Commercial _ Other 1� Number of living units: _r^ Number of bedrooms y, Lot size �+__� f.•— f ' _ Character of soil to a depth of 3 feet: Mater table depth SEPTIC TANI, (7jType/Mfg u _ Capacity _ No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation _ Property Line DESTRUCTION ❑ _ - LEACHING LINE No. a Length of lines �'� f Total length/size _ f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size ,f, Number SUMPS El 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. Hone Owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which thi; permit is issued, I 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 r,,, this permit is issued, i shall employ persons subject to workman's compensation laws of California." The appIican— t / ff�required inspections. Complete drawing on reverse side. Signed X 4: tai y�/�! Title: �- �s� Date: FOR DEPARTME SE ONLY Application Accepted by ayJ2/ Area ❑ Stk 466-6781 Additional Comments: _ ❑ Lodi 369-3621 L] Pit or Groat Inspection by _ Date Manteca B23-7104_ F+nal Inspection by Date '�' [� Tracy 834-6395 Applicant - Return all copies to: EnvironmentA tlealth Permit/Services 1601 E. Hazelton A"., P.U. Bol Z009, 'tk., -• L!G'. rDaitIFEE E AMOUNT REMITTED ASE UNiTI D i PERMIT NU. lNfa EH 13-2: REV. 10.+82 14-26