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`/ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Telephone AVE., STOCKT66-678ON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED e2 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 -anndRegulations of the San Joaqu n cal Health District. Job Address J , .� C" S "� _Subdivision Name Owner's Name 57 Address h Phone Contractor's Name License No. Phone 53ik 27,P 7 W TYPE OF WELL/PUMP WORK: NEW WELL D WELL REPLACEMENT E] DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR F-1 OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial E3Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private r_1 Gravel Pack C]Tracy Dia. of Well Casing Public G Other E3Delta Type of Casing Ej Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Oone3jcj Type of Pump X H.P. � State Work Donelftml�/fY_�+- - Well Destruction Lf Well Diameter Sealing Material (top 50') ^�`�' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is U available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Mo. A Length of lines Total length/size FILTER 8ED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS U 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. 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 workmank 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 applicant s call f al u'� irfS ions. Complete ddrraww,ing h0 'wee snide. pate: Signed X � �Y 69az rsf� L�— p FORAE�ART ❑USE ONLY Applicati Accepted by �� Area �� Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date (� Manteca 823-7104 Final Inspection by /1�1�J. / �— Date Tracy 835-6385 Applicant - Return all copies to: Environmental HealPermit/Services tfi 1601 E. Hazelton A1,91 P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO INFO NAM 193—i r EH 13-24 REV. 10/82 10/82 500 14-26