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DEZI:- -'N JCACLit LDC d .IiT 1601 c 4AZELTON J S`.UCtTUN, CH PERMIT NO. Telephone (209) 466-6781 _ p L DATE ISSUED 6 21 PERF!iT EXPIRES L YEAR FROM DATE ISSUE"u (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 comp1 ion a with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rulem Regulations lzof heN..San Qui ocyl Health District. Job Addres .�lELt4it N, L!' .rf.A Subdivision Name L Owner's Name n�gd/( ,//a` r'-X�61I.+'�--{{ Address :J nv �7 Phone Cont rat ton's 7m&g...�,ty >rf.�tr/�f.-acti.lw,Q2 Cq License No. rX Gr�R Phone p -5�8� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR L7 OTHER LJ W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FCD. PROP, LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ �O r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom Manteca Dia. of Well Excavation Lf Domestic/Private Gravel Pack Q Tracy Dia. of Well Casing r I7 Public G Other Delta Type of Casing Irrigation Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical FI Other ,Type of Seal Surface Seal In sta}led by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') bi TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION �No septic tank or seepage pit permitted if public sewer is h. available within 200 feet.) _ Installation will serve: Residence ^"'�Commercial .2 Other Number of living units: Number of b _pe,drooV Lot size ! Character of soil to a depth of 3 feet: Water table depth Q SEPTIC TANK �� Com Type/Mfg - il,,.elra. Capacity 0 No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposjl C. SEWAGE SYSTEM Distance to nearest: Well �U Foundation Property Line s{- DESTRUCTION LEACHING LINE Ti_'No 8 Length of lines — q0. Total length/size 1776 FILTER BED Distance to nearest: Well ;�'�,. Foundation 1e Property Linei—_ r SEEPAGE PITS Depth .Y^! Size 113 Number Z3F SUMPS ❑ Distance to nearest: Well !QQ_` Foundation �. Property Line DISPOSAL PONOS ❑ t r. 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: "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-contractilig 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 in call f all equired inspections. Complete drawing vfn verse side. Signed K Title: v. Date:C2 FOR DEPARTMENT USE ONLY 4 Applicat Accepted by ^-1 J 4 Area Stk 4fi6-6781 Additional Continents: '�`-'�`T-- Lodi 369-3621 ` Pit or Grout Inspection In Date --/r��-J /�,( ///�—�., ❑ Manteca 823-7104 Final Inspection by Date Y L7 Tracy 835-6385 Applicant - Return all copies o: Environmental Health Permit/Services 1601 E. Ha elton Ave., P.O. Box 2009, Stk., CA 95201 LFEEI BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 7 6Z3 T3 3— (o 0,5 6 EH 13-24 REV. 10/82 10!82 500 14-26