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APPLICATION FOR PERMIT SAN JOAQLi.", LOCAL HEALTH DISTRICT PERMIT NO. O✓ - 7 7 1601 ETelephoneN AVE. 466678ON. CA q ` DATE ISSUED / a PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED (Complete in Triplicate) Bance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for we11,'Dump Application is hereby-made to the San Joaquin Local Health District for a permit o construct and/or install the work herein described. This aPPlication is made in camp and;the Rules and R�lat�;t f the:San ,baqui! Local (Health District. Qw �% Subdivision Name hone Job Address % Address A't Owner's Name -L /:•A1 _,�Zr/-Jflil —4.�'� _ Phone Contractor's Name y License No. 'REPLACEMENT ❑ DESTRUCTION ❑ TYPE Of OF WELL/PUMP WORK. NEWIMELI C] WELL OTHER Lj PIMP INSTALION C) SYST- REPAIR PROP. LINE __ W SEWER LINES DISPOSAL ILO. I DISTANCES SEPTIC TANK OTHER WELL PITS/SUMPS AGRICULTURE WELL FOUNDATION �I -- '-' C7 - CONSTRUCT[ON SPECIFICATIONS �r TYPE OF WELL PROBLEM AREA s ,- INTENDED USE _ 1 Dia, of Well Excavation J Bottm Manteca I❑ Industrial O�^i G FT Die. of Well Casing ❑Oonesiic/Prtvete ❑Gravel Pack }racy�..r�.�.+.� ❑ Public r Other ❑Delta Type of Casing �WM'ox, ❑Eastern Specifications ❑Cath Irrigation Protections„�. Depth Depth of Grout Seal 17Geophysical Type of Grout Surface Seal Installed by l I [j Other' ( i f H P Stet. Work Gone Repair Work Done ❑ Type of Pump_ i Seal Sng Material (top 50') Well Destruction ❑ Well Diameter Filler Material (Below 50') i Depth Pit Permitted if public sewer is S available within OD feet.) TYPE OF�SEDT IC WORK: NEY INSTALLAtION ❑ REPAIR/AODIT IDN � (No septic tank or seepage p • !^ Commercial Other ______— ,Q,G w ' �V l Instal -wH}-serve: 0..s;dente y lot site _�_--T' 1 Nimber of bedrooms water table depth NUMer of living units: --� i Character of soil to a depth of 3 feet: Capacity No. Compartments j SEPTIC TANK Type/�9 Method of Disposal y_— p F • Capat ity PKG. TREAT PLT. Type/Mfg property line Poondatioo- i SEWAGE SYSTEM Distance to nearest: Well u — 1 DES7RutTTON /r T Total length/size• LEACHING LINE No. a'Length of lines DrppertY J-ine - i Foundati,`Ln- FILTER E Distant to nearest: Well — Slze Number __ SEEPAGE Pi75 ❑ Depthf _ Prpperty_Lige ' . Foundetian l. . - SUMPS A ❑ Distance to nearest: Yell i .1 ,�ys DISPOSAL PONDS ❑ � t ;.a. I hereby certify that 1 have DFepared CMS application and that the work w;ll be done in accordance with San Joaquin county 4 w' '• ordinan[es, state laws, and rules and regulations of the San Joaquin Local Health District. person es such mender as to become subject to workmank comPe^sat ion laws of California.'-hic I. Home owner or licensed agent's signature cerci ties the following: 1 certify that in the performance of the work for which this permit is issued, i shall not empl oy!any D �..� Contractor's hiring or sub-contract,ng-sl9ansusuD,7ecti to wo kmao sl cam^pensationr laws of California•"font. of Cne work for w ,c .. _ this Permit is issued. t shall employ pe The applicant must ca 11 required inspections. Complete drawing on reverse side. Date: Title: .r Signed X '�—�-- ❑ -*- 466-6781 • FOR DEPARTMENT USE ONLY Stk Area �_. Application Accepted OY� ❑ Lodi 369-3621 Additional Crn�e^ts: �Le �..Montpgca 623-7104- ( 0 Tra Qy 835-6385 Pit or Grout Inspectio1 by pateq- i • P.O. Box 2009, Stk., CA 95201 1 Final Inspection by '-- Applicant - Return all copies`to: Environmental Nee ith it/Services 1601 E- Hazelton Ave.. PERMIT N0. FEE BASE• : AMOUNT REMITTED RECEIVED BY DATE AMOUNT DUE �q .ap3, 5- 7 iMFO EH 13-24 REV. 10/82 60 14-26