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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6731 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address aO1G19,-,, Owner's Name e Lot Sirec - PM ______ Phone License -.PS°226 Phonar— TYPE OF WELL/PUMP: ,DISTANCE TO NEAREST: NEW WELL Fr PUMP INSTALLATION 0 SEPTIC TANK FOUNDATION WELL REPLACEMENT SYSTEM REPAIR SEWER LINES AGRICULTURE WELL DESTRUCTION 0 ' H --- • ' DISPOSAL FLO. PROP. LINE OTHER WELL PITS/SUMPS CONSTRUCTION SPECIFICATIONS Die. of Well Excavation Dia. of Well Casing INTENDED USE C.L.' Industrial Domestic, Priate • 71 Public I Irrigation --Repair Wolk-Mine " Li Well Destruction TYPE OF WELL PROBLEM AREA Open Bottom E Manteca 0 travel Pack Li TraCy. El Other • Delta J.L.Approx, Depth I Type Of PumP " Well Diameter Eastern"""" —Spedifications - Type of Grout Type of Casing " • Depth of ,Grout Seal ,• Surface Seal Installed by :Fr" ""--- • Statb -WaYk Done Sealing Material (top 601 Depth f*-- Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONS REPAIR/ADDITION ' I \'• r of PLT. 0 / .11 . •,711 ,-,...<-- IlDistance to nearest: ' Weil ri VV 1, Foundation /0 Property Line -5 s. ,•• tj — VC> ••,,,' N i / • , U II.1 Distance to nearest: Well .,5 / 7:1 Foundation' / 6 ProPerty Line ,5 II / /1 .,) SEEPAGE PITS X ii Depth v95- Site ,.3t, ''-'n '`--`, • f/ilumberf \•,...73.." / SUMPS • . I:11 Distance to nearest: Well _WO ' • Fotecdation •-•//,e) - PropeAc'.L•ine • 'S-- DISPOSAL PONDS El ' ,•- '• / s, .i .- I hereby certify that I have prepared this application and that the work will be done .in.,-aCconiance with ,an Joaquin county ordinances, state taw, 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 workman's compensation linvs 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 compensa- tion laws of Californie.- '•JI The applicant must cilfor ill' uirad inspections. Complete drawing on reverse fi) Tide. or. •••\ a FOR DEPARTMENT USE ONLY ,,101c Application Accepted by " Data r Area Igor Grout Inspection by faireir - AWL. Date9:70 f5V Final Inspection by 7_-J Additional Comments: o Stk 466-6781 0 Lodi 369-3621 El Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2039, 5/k., CA 95201 DESTRUCTION I ! (No septic system permitted if public sewer is available within 200 feet./ SEPTIC TANK PKG. TREATMENT Installation will serve: Number of living units Number Character ot soil to a depth of 3 feet: Residence Commercial Other droOrn - Water table depth Capacity/6a, No'. Compartments Oeihod of Di,sposal LEACHING LINE FILTER BED No. & Length of lines Total length/size Signed Date! r2) Eli 13-2.4 !MEV I/ 61 Eli 14.26 FEE INFO AMOUNT AMOUNT DUE AMOUNT REMITTED CK * CASH RECEIVED BY DATE PERMIT NO. 3 II