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1501 E. "::EL TO'. '.c. S' •.?u:, . rFr"' N0, 9 S Telephone (2091 4E DATE ISSUED O� PERMIT EXPIRES 1 YEAR FRO" D•'E ISSUED o (Complete in Triplicate) 3 Application is hereby made to tl,e San Joaquin Local Health District for a permit to construct and/or install the work herein :r ri scribed. This application is made in comoliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump ani the Rules and Regulations Qof the San JOaQUin Lo 1 Health Oist�ict, Job Address l Subdivision Name 4 Owner'i Name Address � t-+ Phone 1 Contractor's NalZ License Na jd 2 X/ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION W v PUMP INSTALLATION SYSTEM REPAIR U OTHER DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP, LiNE C FOUNDATION AGRICULTURE WELL OTHEP W- PITS/SUMPS 'r INTENDED USE TYFE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑Open Bottom ❑Manteca Dia, of Well Excavation V U Domestir/private ❑Gravel Pack ❑Tracy Dia. of Well Casing ?. ❑Public G Other L_1 Delta g . irrigation Type Of Casing �a( L_i 9 Approx. ❑Eastern Specifications { ❑Cathodic Protection Depth cif Depth of Grout Seal Geophysical �I Other Type of Grout ,- ❑ Surface Seal Installed by +i• Repair Work Done ❑ T s pa Type of Pump H,D, State Work Done Well E.estrw tion ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') b TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION L4P_(No septic tank or seepage pit permitted if public sewer is ^lr. available within 200 feet.) Installation will serve: Residence _v Commercial _ Other i Number of living units: Number of bedrooms Z Lot size O C' Character of soil to a depth of 3 feet: ( _ - LA k4, Water table depth . SEPTIC TANK [1 Type/Mfg Capacity No, Compartments ,.T PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method o• Disposal t SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Li..e DESTRUCTION ge LEACHING LINE No. A .ength of lin S S ' Total length/size FILTER BED ❑ Distance to nearest: WellQ' Foundation !_ Property line ; SEEPAGE PIIS Depth Size Number L SUMPS ❑ Distance to nearest: Well Foundation Property Line �QL aTg 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 a9ent'f signature certifies the following: "1 certify that iti the performance of the work for which this permit is %sued, i shall not employ any person in such manner as to become subiect to workment compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which thiy pomit is issiAld, I s ll employ persons subject to workman's compensation laws of California." TMo applicbt WW 1 ired inspections. Complete drawing on reverse side. Signed K Title: A_,%. Date: l 3 + FOR DEPARTMENT USE ONLY 31 Application Accepted by Area ❑ Stk 166-6781 Additional Comments: Lodi 369-3621 Pit or GroutInspection Date �] Manteca 823-7104 slth F1nAl Inspection by to ❑ Tracy 835.6385 Applicant - Return all topic Envir 1 Permit/Services 160 E. zelton Ave., P.O. Box 2009, Stk., CA 95201 " FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PEFAITddNO. i t INFO y. EN 13-21 REV. 10/82 10/82 500 '•..1~ 14.26 ..,'a'..�a,' ,• 'ay. r.:.,,,. ..,:«w.xYpId110f;tCgkA.Y3Rl�aJa+�k:f..+Rdi$;Ur -��y�,yoy�