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�. %✓ ti.I APPLICATION FO PE=' - S'I, JO�OLi:, LUCK._ •,c=..T� .,,.,-RiCi 1501 E. hAZELT01i .A'+L., STU:�Tu+�, PERMIT NO. -{� Telephone (209) 466-6731 DATE ISSUED 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �40 JGb Address 7 �J Subdivision Name Owner's Name Address �='<_ `-7zv� ,.e ,Phone Contractor's Name .. ..'License No. 3,--X -Z,6 Phone 60 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT r II DESTRUCTION U PUMP INSTALLATION 0 SYSTEM REPAIR L-21 OTHER tI 1 6 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 I_jindustrial (_j Open Bottom ❑Manteca Dia. of Well Excavation _ l_JDomestic/Private EJ Gravel Pack U Tracy Dia. of Well Casing Public �j Other LJ Delta Type of Casing E] irrigation Approx. O Eastern Specifications _ �11 ❑Cathodic Protection Depth. . Depth of Grout Seal ( (Geophysical Type of Grout [JOther Surface Seal Installed by ba Repair Work Done Ej Type of Pump N.P. State Work Done _ S Well Destruction (_J Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U R DITLON' 1- (No septic tank or seepage pitpermitted ifpublic fsewe )is installation will serve: Residence _ Commercial Other LI available within 200 Number of living units: Number of bedrooms Lot s ze ff Character of soil to a depth of 3 feet: 944, C!'�• Water table depth :74 SEPTIC TANK Type/Mfg z•/1atF%� Capacity No. Compartments u PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well /!>��Foundation _ f Property Line DESTRUCTION LEACHING LINE Ej No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth y Size 3 4, Number SUMPS EI Distance to nearest: Well -foundation Property Line _ 1.r DISPOSAL PONDS ❑ -� ; n ,�� / -��. IV 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 `ollowing: "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 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 which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant m _t call for all required inspections. Complete drawing on reverse side. >sTitle: Date: T Signed % sly�',�l/• ��"'' R DEPARTMENT USE NLY E] Stk 466-6781 Application Accepted by ' Area Additional Comments: Lodi 369-3621 Pi or Grout Inspection by _ Date S O �J Manteca 823-7104 Final Inspection by Dater Tracy 835-6385 Applicant - Return all copies to: Environmenta Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rFE BASEAMOUNT DUE AMOUNT. REMITTED RECEIVED BY DATE PERMIT NO. O c-, 10/82 500 EH 13-24 REV. 10/82 ,n 9A