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APPLICATI31 FOR•PERMIT SAN JCAQ�1'1 LOCAL ti_«iLTH DISTRICT 1�^ 1601 E. *iAZELTON AVE., STOCKTOV, CA PFR�'1'. NC. Telephore (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FRCN DATE ISSUEG ;Complete in triplicate) Application is hereby made to the San Joaquin Local Hea th District for a permit to construct and/or Install the work herein described. 7nis application is made in complidnce witr San ,oaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations o` the San Joac.uin Local Health 04strict. Job Address q Subdivision Name _ r Owner's Name i!. Address 14 171 °hone.aw, Contractor's Name Jy1 (�mLicense No. .3L$2.Z� _ _— Phone •• -- �AA CatJ TYPF OF WELL/PUMP WORK: NEh WELL E] WELL RCPLACEMEVT DESTRUCTION L] PJMP INSTALLAf1ON C] SYSTEM REPAIR OTHER _i 1 DISTANCE TO NEAREST: SEPTIC TANK SEWFR LINES ti _ D.SPOSAL FLD _ PROP. LILAC FOUNDATION AGRICULSURE WELLUIHER WILL PITS/SUMPS .• a INTENDEC USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOVS Industrial _J Open Bottom 71 Manteca Dia. of Well Excavation - V lJ Domestic/Private 7Gravel Pack Tracy 31a. of Well Casing Li Public ,_I Other ❑Delta Type of Casing Lj Irrigation Approx. []Eastern Specifications r �]Cathodic Protection Depth Depth of Grout Seal [ Geophysical Type of Grout L]Other Surface Seal Installed by Repair Work Done Type of Pump _ N.?. _ State Work Done Well Destruction Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 50') TYPE Of SEPTIC WORK: NEW [NSTALLAT:ONRF.PA:R/ Do IT ION 1/j (Vo septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Reside a ✓-� Commercial _ Other -� J f Number of living units: Number of bedrooms Lot size �,� ��nc/ +j Character of sail to a depth.of 3 feet: Water table depth SEPTIC TANK �j Type!Mfg Capacity No. Compartments �• "°'=�' PKG. TREATMENT PLT. 1=; Type/Mfg Capacity Method of Disposal { SEWAGE SYSTEM Distance to nearest: Well Foundation_ Property Line _ DESTRUCTION -•_- i`w LLACHING L:NE No. L Length of lines I Tota•r length/size I .._4ILTER BED [) Distance to reares.: Well _� G Foundation Property Line S1 t SEEPAGE PITS 71 Depth _/®�_• Size /4,_jNumber _ _, •S'�'e��" N SUMPS Lo T Distance to nearest: Well gC7(,� F6undatior�_IAVI `-Property Line D15POSAL PONDS [1 �� *� I hlereby certify that I have prepared this application aid thatthelNork'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 perforinthe o. .he work for which this per-nit is issued, 1 shall not employ any person in such manner as to become sub'ect to workman§conpensation laws of California." Coltbractor's hiring or sub-contracting signature certifies the following: ": certify that in the performance of the work for which lll{ this pernit is issued. I shall eaoloy persons subject to workman's compensation .laws of California." t The applicant m•st call or 11 required inspections. Complete�drawing on reverse side. Signed X_— ^t.lr - Titter I�""J _ Date: FOR DEPARTMENT.USE ONLY ion 5tk 466-6781 w C V' Applition'Atcepted:ay Are _ ,_ Lodi 369-3621 Additional Comments: i Pit. or Grout Inspection C Oate Manteca 823-7104 k Final Inspection by Oat: C Tracy 835-6385 T _ -- ( Applicant - Return al.l copies o: Environmental Health Permit/Services 1601 L h.%ze'ton Ave., P.O. Bnx 2C09, Stk., CA 95201 [EE AASt AMOUNT DUE A+iOUN- REMITTED R=CEIYED BY DATE �PFRMIT N0. 1 :NFOX4-3 f 1 - 10182 500 E:i 13-24 Rr-V. 10132 1d-26