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�• ... M d ! APPLICATION FOR PERMIT SAN JOAQU'i?: LOCA! HEALTH DiST.Ri•CT it t 1'60-1-E,,HAZELION AVE., STOCKTOTI CA - 9')CZ,# PERMIT NO. — s// Telephone (209) 466-b78'i 31„” }.v EJ, Tit=— �— a DATE ISSUED S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _i6: AL w (Complete in Triplicate) i .%TH + - — Application is hereby made to the San Joaquin Local Health District for"a permit 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. ��•�� Job Address b- b Subdivision Name Owner's Name dress A" �� Phone 71 Contractor's Namer�. .License No. Phone, TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM RE AIR ❑ OTHER ❑ DISTANCE TO NERREST: SEPTIC TANK SEWER LINES f f DISPOSAL FLD. PROP. /LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial `- ,Open Bottom ❑ Manteca Dia. of Well Excavation Domes"ticYPrivate ❑ Gravel Pack ❑ Tracy Dia!of'Well Casing "- i ❑ Public ❑ Other ❑ Delta Irrigation Type ofrCasingi. a � , �I 9 Approx. ❑ Eastern Specifications Y ❑Cathodic Protection Depth #k ❑Geophysical Depth of F-1Other Type of rout } Surface ,4q ed by Repair Work Done ❑ 'Type of Pump H.P. C7_1 State Work Done Well Destruction ❑ Well Diameter / Sealing te`iall [t�`p �0') Depth �� Filler Material' (lBelow'SO ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms ; Lot size Character of soil to a depth of 3 feet: s Water table depth SEPTIC TANK Fj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number —�„ SUMPS" -'"""""""TCS Di'stance•-tro"n'eb'rest:;�We�N =-��-:.Foundation�^�--"� � - Property-Li.ne•--�:.a-.••- _ — 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 to become subject to workmans 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 " this permit is issued, I shall employ persons subject to workman's compensation laws of California." r The applican must all fora 1 required ins ections. Complete drawing on reverse side. i Signed X - - Title: Date: 'Z r 1 ip EPARTMENT ONLY Application Accepted by Areas -- ❑ Stk 466-6781 AdditiL,,ut�Zpetion ts: Lodi 369-3621 e Pit orcby Date ❑ Manteca 823-7104 Finalction by DateTracy 835-6385 Applicant - Return a 1 copies to: En vi m ntal He It Permit/ rvices 1601-E. Hazelton ve., P Box 2009, St�., CA/95201 � 2 FEE BASE AMOUNT DUE AMOUNT REM11TED RECEI D BY DATE PERMIT N0. INFO TIP A V./ EH 13-24 REV. 10/82 �` �` '� / f082 .5"00 �y�