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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, 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. E., _ City Lot Size PM ' _ , or• Job Address Address Phone Owner Nam. S contfactor he_CA-adress 30 (.5-, /4L-0:_y__ N0.3'..2,79, 42— *4 TYPE OF WELL/PUMP: TION 0 HtILI 5 PROP. LINE--"-- PITS/SUMPS _ arT NEW WELL-- WELL REPLACEMENT Li DESTRUC PUMP INSTALLATION 5 SYSTEM REPAIR D OT 3 Li INTENDED USE Industrial IX-Domestic/ Private Fl Public I Irrigation Repair Work Done Li Well Destruction El TYPE OF SEPTIC WORK; NEW INSTALLATION Li 1 Installation will serve: Residence .. Commercial _ Number of living units: — Number of bedrooms Character of soil to a depth of 3 let: _ Water table depth _ SEPTIC TANK n Type/Mfg _. Capacity No. Compartments PKG. TREATMENT PIT. D .! 4 Method of Disposal Distarice to nearest: Well Foundation Property Line i DISTANCE TO NEARES - T: SEPTIC TANK _Iliger± SEWER LINES . -----. DISPOSAL FLD / ---- FOUNDATION -- AGRICULTURE WELL OTHER WELL TYPE OF WELL CONSTRUCTION SPECIFICATI2NS 0 Open Bottom Dia. of Well Excavation _ of Y—Gravel Pack '_racy PROBLEM AREA D Manteca 'A-Tracy El Other ( [Ti Delta Depth of Grout Seal _g6 Approti. Depth I I Eastern Surface Seal Installed by Type of Pump ___ H.P. ___ State Work Done Well Diameter __ Sealing Material (top 501 _ Depth a Filler Material (Below 501 REPAIR /ADDITION I I DESTRUCTION l I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i_PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Other (No septic system permitted it public sewer is available within 200 feet.) Dia. of Well Casing Specifications Type of Grout --_ Phonea7— AMOUNT DUE AMOUNT REMITTED Co- CK CASH RECEIVED BY _.\ PERMIT NO. DATE . EH 13-24 (REV. 5) EH 14-26 LEACHING LINE El No. & Length of lines Total length/size FILTER BED Li Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ SUMPS Li Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed agent's signature certifies the following: 1 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 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 California." „ ....11111/2.1V,9 ,/I 14,17 t fo all req Date Final Inspection by Date Additional Comments: Cl Stk 466-6781 C Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Number The applic Signed X Application Accepted by Pit or Grout Inspection by inspections Complete drawing on ;use sid: Title: ..Z.W.ZAL.. FOR DEPARTMENT USE ONLY Date Are. uS Date: