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APPLICATION FOR PERM11 :;SAN JOAQUiII LOCAL HEALTH DI�TRiI�T 150.1E,-JiAZELTON AVE., STDCKTQNA-. yf �' PERMIT " Tele 466-671`r i �.. ' Phone 3„f 209) _ -. :. DAYE ISSUED < Ik PER_MIT EXPIRES 1 YEAR FROM DATE- ISSUED. _ (Complete in Triplicbte) Application is hereby made to the San Joaquin Local Health Di- trict`for a'pe it 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 and.Regulations of the San Joaquin Local Health District. Ik Job Address a r Subdivision Name owner's Name LVIA1. dress �L' Phone 9 Contractor's Name jg�¢*�• - .License No. f�3 ��fya'� Phone"� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT 1K DESTRUCTION❑ /s :` / PUMP INSTALLATION ❑ SYSTEM RE.AIR ❑ OTHER U A-c 9-e, DISTANCE TO NEAREST: SEPTIC TANK (`�_ SEWER LINES DISPOSAL FLD. PROP, LINE 1 FOUNCATION AGRICULTURE CELL OTHER WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM AREA ^' CONSTRUCTION SPECIFICATIONS #� Industrial „Open Bottom ❑Manteca Dia. of Well Excavation ` : �+' •� Domest'itlPrivate- ❑Gravel Pack ❑Tracy Die.”6fVel1 'Casing ❑Publ is C-j Other ❑Del to ., Type of,-Casing .ice 4a.f,,,._ LJ Irrigation Approx. ❑Eastern. Specifications ❑Cathodic Protection Depth r Depth of Grout Soal��.�•. ❑Geophysical Type Of rout Other Surface Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing"flateiialj(top 501) Depth Filler Mater aIjBAowlsb'} �w TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITI4N (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other " j Number ofliving units: Number of bedrooms 'Lot size Character of soil to a depth of 3 feet: k Water. table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 1 Foundation Property Line SEEPAGE PITS [J Depth Size Number SUMPS" "'�0lstanc2`to�rre ast�; We}a 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 tc 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 t this permit is issued, I shall employ persons subject to workman's compensation laws of California." r The applican�mustt 1I for 1 required ins ections. Complete drawing on reverse side. ( # Signed X Title: Date: c' EPARTMENT ONLY Application Accepted by Gtr ° � �, Area ❑ Stk 466-6781 Addition ents: Lodi 369-3621 + Pit or Grout nspection by Date ❑ Manteca 823-7104 Final ection by Date $ Tracy 835-6385 Applicant - Return a 1 copies to: Envi m ntal Hep]tb Permit/ rviees 16o1•E. H zelton ve.,P Box 2009, Stjt., CA 95261 /y. I FEE BASE AMOUNT DUE AMOUNT REM TED RECEI D BY DATE PERMIT NO. INFO L ' 00, EH 13-24 REV. 10/82 P Z 14-26ji[iGf,,.Q.