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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComptete In Triplicate? <br /> Application is hereby made to the San Joaquin Local Health District of a permit to construct and/or install the wort herein described,This application is <br /> made in compliance with San Joaquin County ordinance No.549 for sewage or No.18M for well/pump and the Rules and Regulations of the San Joaquin <br /> L Local Health District. <br /> Job Address <br /> 229 Moffat Street City Manteca Lot Sue-- PM <br /> Golden Grain -Address <br /> 1111 139th Ave. San Leandro Ph. <br /> f415)357-8$00 <br /> Owner's Name <br /> Water Develop. Corp.Arldfess220 fl. East St. WoodlandLlckeNo.z83326 Phone(916)662--282 <br /> Cor,tfactor_��--- -�-- WELL <br /> REPLACEMENT ❑ DEaTRUCTION 0 <br /> ! NEW WELL X1 <br /> TYPE OF 1MELLJPUMP: SYSTEM P.EPAIR C OTHER Q G.W. Monitoring <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP.LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION . <br /> AGRICULTURE WELL OTHER WELL-2- --PITSISUMPS <br /> LL PAREA ROEr.EM ARCONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE Of WEpia of Wel!Ca�eng <br /> ❑industrial ❑Open Bottom 11 Manteca Dia.of Well Exca��io�CH�- slotted <br /> Type of Casing — Spocifrea[roro <br /> e : 0 Domestic/Private ❑Gravel Pack ❑Tracy Approx 25r Tyye of Grout_zement <br /> ❑ Pudic a Othar sand ❑Delta Depth of Grout Seal __ <br /> ace Seel Instal ed by Water Develop. Corp. <br /> ❑Irrigation SQpprox. Depth 0 Eastern Surf <br /> � <br /> H P State Work Donn <br /> t <br /> Repair Work pone C Type of Pump Sealing Material/tap 50'1 <br /> Well Destruction [_-jWell Diameter Filler Material[Below 50') - <br /> s Depth em mritted it public waver is <br /> TYPE OF SEPTIC WORK: NEN tNSTALLATION G REPAIRIAODITION❑ DESTRUCT)ON Q available withintic 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: CapacityNo.Compartments _ <br /> SEPTIC TANK G Type/Mfg <br /> Method of Disposal <br /> PKG.TREATMENT PLT. <br /> Distance to nearest: Well Foundation Progeny Line <br /> f Total length/size <br /> LEACHING LINE ❑ No.&Length of lines Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> Size Number <br /> SEEPAGE PITS [3 Depth <br /> SUMPS C7 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicat?an and that the work will be done in accordance with San Joaquin county ordinances,state/errs.and <br /> rules and regulations 07 the San Jc"uin Local Health District. I shaft not <br /> Home owner or licensed agent's signature certifies the following:"I can that in the pr,rtormanca of the work For which this perms n isatred, igm <br /> employ any person in such manner as to become aubiect to workman's compensation lawsis�Cad,I shall a Contractor's. <br /> Por a-rring or`-''b,'ect o workman's compoina- <br /> car."dies the following:"i certify that in the performance of the <br /> work for vhich this permit <br /> tion laws of California." <br /> The applicant must cell for all raquired inspections.Complete drawing on reverse side, <br /> Title: Date: <br /> ' Signeu <br /> FOR DEPARTMENT USE ONLY I #,f <br /> � lJZ3ate Area <br /> Application Accepted by <br /> ' Final inspocd%;t'-'Y Data <br /> pit or Grout Inspection by Data <br /> ...Additional Comments:- <br /> ...—,� _...... <br /> frMI C1 Lodi 3t(31321 ❑Manteca B23-71Servio04 _Q Tracy <br /> 0 Sik g9 <br /> Applicant-Return all copies to:Environmental Health Pennitlervier!a 1901 E.Hazelton Ave.,P.O.Box 20U7,Stk.,CA 95201 <br /> FEE OUNT REMITTER RECENED By DATE PERMIT N0. <br /> IEEE AMOUNT DUE AASH <br /> 73 5 1�j �_11 A? <br /> EH 1324IREV 1 a5, <br /> WEN= <br />