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APPLICATION FOR PERMIT <br />SAN JOA0,;N OCAL HEALTH DISTRICT <br />1601 E. HAZELTUNI AVE., SIGCYTON. CA PERM,11 No. <br />Teler,hone (209) 466-6781 GATE ISSUED, S <br />PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Cor olete in Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for A "Mit to construct and/or install the work herein <br />deSCribed. This application is made in compliance with San Joaquin CoiAty Ordinarce No. 549 for sewage or No. 1862 o ei I 1pump <br />and the Pules and Regulations of t S for w <br />A San joaqui� Local#.Wealtp District. <br />Job Address 4J 4!4 7 <br />i s i o Y, Name <br />Owner's NameAddress Phone <br />Contractor's Iar.* License No, Phone <br />TYPE 2F_�_ILL/P"P WORK, NEW WELL 'WELL REPLACEMENT DESTRUCT'XN <br />PUMP INSTALLATIO4 C,'j SYSTEM REPAIR OTHER <br />DISTANCE TO NZAR"T: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. �._[NE <br />FOUNDATION AGRICULTURE WEI!. OTHER WELL i <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Industrial open <br />r-,' manteca Dia. of Well Excavation <br />F-10mTkstic/private Gravel Pack [7 'Tracy Die, of Well Casing <br />Public j—) other F-1 Del ta <br />Irrigation Approx. Eastern Type of Casing. <br />Cathodic Protection — Depth Sp�ificdtions <br />J Geophysical Depth of Grout Seal <br />Other Type of Grout <br />Surface Seal Installed by <br />Repair Work Done [] Type of Pump State Work Done <br />Well Destruction 01 Well Diameter Sealing Material (top 501) <br />Depth Filler Material (Ul vw SO'} <br />TYPE OF SEPTIC WORK: NEW INSTALLATION [.�7j REPAIR/ADD:TION 'J��o septic tank or saeoage pit permitted if public sewer is <br />I ­ available within 200 feet.) tft <br />Installation will serve: Residencolk corywrcial — Other <br />Nor of living units:1 -4r P ,AL4/ Number of bed-2— <br />rooms Lot size <br />Character of soil to a depth of 3 feet:Water table depth <br />SEPTIC TANK Type/Mfg <br />Cdpac i ty No. Compartments <br />PKO, TREATMENT PIT. f_1 Type/Mfg <br />MA�Capacity Method of Disposal Cfx <br />SEWA6E SYSTEM Distance to nearest;1l�Z*F,u.datIon <br />Property Line iT <br />DESTRUCTION <br />LEACHING LINE i — I No. & Length of lines Total length/size --240" <br />FILTER BED Distance to nearest: Property Line A, <br />SEEPAGE PITS 7_1 Depth Size, Number <br />SLkM P S J Distance to nearest: Well Foundation — Property Line <br />DISPOSAL PONDS <br />L-1 Af )D <br />i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />Home owner or licensed agent's signature certifies the following: 'I certify that in the oerforoiarce of the work for which this <br />permit is issued, I shall not employ any person in such manner as to beco�* subject to workman§ compensation laws of California <br />on <br />Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the Performance of the work for whh4 <br />this perinit is issued, I shall employ persons subject to workmates comoensation laws of California." <br />The applicant for VI q4ea inspections. Complete drawing an reverse side. 21J a 14� <br />Signed X_;�= —I Title. Date; <br />DEPA I RTMD47 USE ONLY Area Stk 466-6781 <br />Application Accepted by <br />Additional Comments: _-12 Lodi 369-3621 <br />Pit or Grout Inspectio YIW skate 7104 <br />Oa <br />Manteca 823- <br />Final Inspection by YX te �P,v 0 Tracy 835-6386 <br />Applicant Return all ropi Aso: =Env,,owamental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />.. . .......";�MDU4 <br />�T R <br />BASE AMOUNT DUE AMUNT REMITTED RECEIVED BY DATE PEVOIT NO, <br />ffl 'N FO _..,.....w.__.. <br />EH 15 <br />-24 kEV. 10/82 lo/u 500 <br />14-26 <br />141 <br />