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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . -' tt'v7 ' t (Complete_in Triplicate) ~� 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 C6unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin —Coral Hm3alth D-nstrict.'. :'-`i•-`•'.:-..-.T Job Address 9P:l gi l,ar Roaid - City Ell On _ Lot Smze 5 aCres PM Owners Name :(gh66ter N. Daf fell - Address 2004 N. Santa Fe Ave. , - phone (209)523-1682 1 Modesto; CA 95355 Contractor Chet 'Daniel Construct ddess?J(04,N._Santa.Fe.Aye.._��,Lice se.Mb.�`4`l'Yi401_ , Phone.523-1682 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I TfON AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial -?I ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Casing Specifications 1 ❑ Public it - ❑ Other ❑ Delta Depth of Gro I Type of Grout ) ❑ Irrigation^ --Approz, Depth ❑ Easter Surface Seal Installed Repair Work Done ❑ Type of Pump H.P: State Work Do I t Well Destruction O Well Diameter .Sealing-Material (top 501) i t-: Depth sl fFillar,Matwial (BelowVT •-'� > TYPE OF SEPTIC WORK: -NEW INSTALLATI (J. R AIR/ADDITION O' DESTRUCTION C1 (No septic system permitted if publid sewer is in t ` available within 200 feet.) 1 Installation will serve: Residence Commercial —LOther ` Number of Irving units: I Number of bedrooms!? Character of soil to a depth of 3 feet sand loam), Water table depth 11 SEPTIC TANK7I C( Type/Mfg _ AU eta Capacitylons,No. Compartments FKG. TREATMENT PLT. ❑ ! f i Method of Disposal Distance to nearest,= 1Well: 125%ft:foundation 25 fr Property Line eft- t LEACHING LINE No. 8 Lerfmgth of linea i 2 1`J_neg @ .1002 ea Total length/size t I R" 1 FILTER BED O Distance to riemirest: We Foundation 38t Property Line 130r SEEPAGE PITS O Depth 1 Sizei Number 11 SUMPS ❑ Distance to nearest: I Welk Foundation = Property Line DISPOSAL PONDS O m At I hereby certify that I have prepared this application and that the rk 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, 1 shall not employ any parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the parformance of the work for which this permit is issued,I shall employ peraone subject to workmen's carrpenea- tion Ism of Califomia." I I r t The applicanl,tnust 11 f all requi d nspections. Complete drawing m reverse side. `( l/ Signed x -nu J'/ r I rmtle: 9A1,n Data: March-2,1987 +E' _ OR EPARTM NT USE ONLY Application Accepted by Date Area 0('0��/{�Q` N I Date Final Irropecdon by Data / Pit or Grout Inspection by 1 Additional Comments: ^I�14L'f/x Z t< UyGr/eLtlll� al_ ❑ Stk 4216-6781 ❑ Lodi 369-3821 ❑ Maraca 823-7104 ❑ Tracy 835e385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 86201 t FEE INFO MAOUNT DUE D RN ECEED BY DATE PEflMIYNO. PtJ AMOUNT REMnTE /- aEli13241REV.tiae) ��'� -70 .. ©.J 3Z� C