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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3 b PWL 1601 E. I-IAZELT ON AVE.. STOCKTON, CA Telephone Q09) -6791 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iCompletke in Triplicate) Application is heiehy made to the San Joactuirl Loral 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. 545 for sewage of No. 1882 far welUriomp and the Rules and Regulation's of the San Joaquin Local Health District. Job City-, .. Lot Size _ .._��d-_ PivS Owner's Nam ? . ....I� .__.._ ._.. Addressjh .._ Phone17 Contractor iCensi No.c�ti7rdlshotve TYPE OF WELL!PUMP: NEW WELL El WELL REPLACEME d DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR D OTHER E: DISTANCE TO NEAREST: SEPTIC TANK ._..__._ SEWER LINES DISPOSAL FLO... ,--.. PROP. LINE FOUNDATION AGRICULTURE WELL _ -_._ ..... OTHER WELL—_._..._ . PITS/SUMPS INTENDED USE U Industrial 11 Domestic/ Private Cl Public I I litigation Repair Work Done Wel: Destruction n TYPE OF SEPTIC WORK TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCATiONS _1 Open Bottom ..,,,._........_..�._........._.,_._..�__..................... El Manteca oia, of Well Excavation it Gravel rack L3 Tracy Type of Caning __..... ..__..___-_,__ _ i-1 Other n Delta Depth of Grout Seal -_.Approx. Depth t I Eastern Surface Seal Installed by Type of Pump _.. _. H,P. State Work Done ._ Well Diameter _. _.. Sealing Material (top 501 Depth ? . killer Material lBetow 501 _ NEW INSTALLATION Dia. of Well Casing Specifications Type of Grout ._...... ..... REPAiR1ADDITION ; I DESTRUCTION I , INo septic system permitt available within 200 feet.l Installation will serve: Residence _ Commercial _ Other Number of living units:yle�l Number bedroom. � - Character of soil to a depth of 3 taut: _ dater table depth ` SEPTIC TANK Type/Mfg ��✓�--�� Capacity No. Compartments PKG. TREATMENT PLT. i7-; Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING i,INE 4r' No. & Length of lines FILTER BED 0 Distance to nearest: well _--- Total lenqunlsize ,,......_1410- Foundation ..1410Foundation _. Property Line/?` SEEPAGE PITS Depth ;yf c Size 3a Number ..__,13--- -.. SUMPS i_i Distance to nearest: WPI ..1� J Foundation ._.,� r__ Property Line ,�� DiSPOSAL PONDS 0 SLwer is I hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin county ordinances, static laws, fond rules and regulations of the San Joaquin Local Health DAIrict, 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 laws of California." Contractor's hiring of sub contracting signature certifies the following: "I certify that in the perlofrnance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California " The applicant must call forall inspe 4ons. Complete drawing on reverse side. Si¢ed`wf _ ._ _� `"✓- Title: Date: LL , `•' DEPARTMENT USE ONLY Application Accepted by _ 0118 �._ Area.... _ i 3 Pit Grout inspection by Date _ Final Inspection I Date �' Additional Comrnents: LJ Silk 456-6781 n Lodi 369.3621 0 Mantftca £123.7104 0 Txacy 835-6385 �ppiicant - Return all copies to: Environmental Health ParmitlServicas 1601 E. Hazelton Ave., P.O. Box Zoos, Stk_, CA 95201 . EH 1314 SNEv. i r w o EH 14 22I ck7 - tNfO A OUNT DUE AMOUNT AEMITTEOF H RECEIVED By DATE PERWT'NO