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r• ' "f 'APPL.ICA"ICN FOR PERMIT SAN JCAQi;iN LOCA_ HcALTH vIS7RICT 1601 E. MAZE,-TCN AVE., STCCK'ON, CA PERMIT NO. Teieohone (209) 466-678' DATE ISSUED } PERMIT =XPIRFS I YEAR FROM DATE ISS!lFD r (Complete in Triplicate) r Application is hereby made to the San Joaquir. Local Health District for a permit to constrict and/or install the work herein described. This application is madefin compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump ` and the Rules and Regulations at thefSan Joaquin L,oCall.Health District. Job Address 13 O Sri 6-: �"9 - Suhciv;sinn blame �_.��,_, Owner's Name ,J�C/>/ �'! >er o iV Address /SO 6_e, . If, J74 /✓� 6� ho^e.$.� �� Contractor's Name I elG1or�cLy r�,�.// L; en se No. a''f /123 Phone„7� 67 i TYPE OF WELLrPUMP ODRK: _r NEW WELL WELL REPLACEMENT Lf DESTRUCTION U a D /¢Ci!gyp S k PUMP INSTALLATION , ' SYSTEM REPAIR k� OTHER �r DISTANCE TO NEAREST: SEP-IC TANK .Zo o ��SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTPER WELL PIIS/SUMPS INTENDED USE TYPE OF WEILL PROBLEM.AREA CONSTRUCTION SPECIFICATICNS ' �Industrfal - •Bottom---0-Manteca ^- --•Dia.-of•-Wel1_Excavat-1on� ;�50omestic/Priv8te Grave. Pack (-Tracy Dia. of Well Casing I�Public Other ❑Delta Type of Casing 7<e Lj Irrigation .Q_f1d -_ rox. E]Eastern Specifications [IDepth Protection -- 7T r Depth of Grout Se�l i_]Geophysical Type of Grout G@ ,>I C� _ I J Other ' Surface Seal Installed by Repair Work Jone ❑ Type of Pump l H.P. State Work Dore well Destruction LI Well Diameter;J Sealing Material (top 50') _ C Depth �I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION D (No septic-tank or seepage pit permitted if public sewer is available within 200 feet.) Q Installation will serve: -Residence _ Commercial _ Other V .y \• Number of living units: Number of bedrooms __ Lot size Character of soil to a depth of 3 feet: - Water table depth Z SEPTIC TANK F] Type/Mfg` Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg _ - _ _Capacity Methodof Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation _ Property Lane DESTRUCTION I i _ Total lercth/size r f LEACHING LINE ❑ No. & Length of lines. _. - FILTER BED Distance to nearest: Well Foundation -� Property Line SEEPAGE PITS [] Depth I Size Number SUMPS t_1 Distance to nearest: Well 'Foundation _ Property-Line r DISPOSAL PONDS Q I hereoy certify tna: i have prepared this application and that:the work will be done it 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: ". 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 4 compensation laws of California." Contractor's hiring or suh-contracting signature certifies the following: "I certify that in the performance of the work for which i this permit is issued. I scall employ persons subject to workman's compensation laws of California." The applicant must call `or all required inspectior.j. Complete drawing on reverse side. Title: �_ 0, . Date:• 0 7 Signed X d g : F DEPARTMENT USE bNLY Stk 6616781 �/ C Application Accepted by Area Additional Comments: Lodi 369-3671 7104 Pit or Grout inspection by Date Y (� Manteca 823-6385 1 Final Inspection by Date } Tracy 835-6385 R Applicant - Return all copies'to:.• Environmental Mith ermit/Services 1601 E. Pazelton Ave C. Box 2009, Stk., CA 95201 1 FEE BASE AMOUNT DUE AMOUNT RE M:TTED RECEIVED By DATE ~PFRYIT NO, i .10/82 500 1 EH 13-24 REV. 10/82 l 9 •14-26