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IT APPLICATION FOR PERM DISTRICT SAN JOAQUIN LOCAL HES OC♦<TON, CA 1601 E. HAZE�TON AVE., 209) 46B-67a1 Telephone ( r FROM DATE ISSUED I YEAR ` PERMIT EXPIRES } Triplicate) This application is (Complete In an Joaquin ' and the Rules and Regulations of the S t al Health District for a pe construct862 for we WeillPUMP the work herein descn e Application is hereby made to the San Joaquin Ordinance No.549 for sewage or Bance with San Joaquin County PM�Y made in comp � Lot Size Local Health District. r City # Phone Job Address Address ,ry74 f Phone Owner's Name License Address_�� DESTRUCTION ❑ Contractor ❑ WELL REPLACEMENT ❑ _ NEW WELL. SYSTEM REPAIR ❑ PROP. LINE TYPE OF WELLIPUMP: DISPOSAL FLD.l PITSISUMPS 1 PUMP ILATION ❑ THER -1 SEWER LINES ------ WELL ! t DISTANCE TO NEAREST: SEPTIC TAN - r AGRICULTURE WELL t FOUNDATION StRUCTION SPECIFICATIONS Dia of Well Casing TYPE OF WELL PROBLEM AREA INTENDED USE ❑ Monte Dia. of Well Excavation Specifications D industrial ❑ Open Bottom acY �^_.,-.,..rT Ve of"Casing "" Type of Grout �---r D Gravel Pack ❑ Delta Depth of Grout Seal - ❑ Domestic/Private Cl Other i.I Eastern Surface Seal installed by 1-1 Public App , Depth t State Work Done i I irrigation H.P. • Ty f Pump �� Sealing Material atop`,p 1 r. y Repair Work Done ❑ 1 Well Destruction ell Diameter Filler Material SBelow.50'1 stem permitted it public sewer is Depth DESTRUCTION I I ahvailabper+m thin 200 feet.) � . i TYPE OF SEPTIC WORK: NEW 1NSTALVATION I-1 REPAIRIADDiTI / Commercial other J�� A ' Installation will serve: Wateti fable depth Number of living units: Number of bedrooms No. Compartments Character of soil to a depth of 3 feed GSL Capacity----- i-1, Type/Mfg Method of Disposal` SEPTIC TANK t, ? -- •Property Line PKG. TREATMENT PLT.❑ y; —`—Foundation,_�— • � Distance to nearest W�SeII --- - rX Z J Total length/size r No. & Length of lines 4 /d ! property Line 1� LEACHING LINE Well Foundation — FILTER BED ❑, Distance to nearest: Number � Size- - SEEPAGE PITS Depth „ ! s�J Property�Line--5�` ' SUMPS LJ Distance to nearest: 1NelI Foundation�—� ; DISPOSAL PONDS ❑ ^r ` Joaquin county ordinances, state laws, I hereby certify that I have prepared this applicationlCh pistr ctthat he work will be done in accordance with San rk far whicfi this pe m t is issued, I hall nr rules and regulations of the San Joaquin Local Hea g• Home owner or licensed agent's signature cert ifies the followin 1 certify that in the performance California."s Of the w employ any person in such manner as to become subject u jece of the workman's k for compowhich s per tion is issued, I shall employ persons rsubject to sub-woarkmantlscomperr certifies the following: I certify that in the pe tion laws of California." f '� The applicant must call for all required inspections. Complete drawing on reverse side. Date: A �� t T`' Title: Signed X t a FOR DEPARTMENT USE ONLY Date Area Application Accepted by - Date Pit or Grout Inspection by ---Date'—��Final-Inspection by - f Additional Comments: r62 ❑ Trac —835-6385 ❑ Stk 466-6781 L3 Lodi 369-3621 ❑ Manteca 823 7104 y Stk., CA 95201 r Applicant- Return all copies to: Environmental Heelth'PermitlServices"1601 E: Haielton Ave., P.Q. Box 2008, 1 GK REGEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT RE�M7IT�TED j c Q Q INFO • r EN 1324(REV,I�n si � a EH 14-26 -. -