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.4‹ urre j- Ai 0 izk "We Vie a s ceimpee tcr P,5444fr, 1 I Industrial Ll Open Bottom CI Manteca )4, Domestic/Private Gravel Pack D Tracy 1'1 Public II Other )Delta 1 1 Irrigation ISWApprox. Depth I I Eastern Repair Work Done D Type of Pump H.P. Well Destruction 11 Well Diameter Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation 7" Dia. of Well Casing 2" Type of Casing PVC /67. SrEEL Specifications Depth of Grout Seal 2.-5 rre-T- Type of Grout Surface Seal Installed by P.C.• ExPt..00A-riOFJ State Work Done Sealing Material (top 50') -64€44E.4*--718C-44-TOPTIT Filler Material (Below 50') Date: tion laws of Cal ia." The applica call for Signed X lions. Complete drawing on reverse side. Title: eP/`e'S. ; AJ 6 Application Accepted by Pit or Grout Inspection by Additional Comments: FOR DEPART ENT USE ONLY Date I Area (742.Y R Final Inspection by Date Date 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 (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 0...00K 12,b 7411i1 fsi /0 HOLT FL Oft[) City i—jOi-T Lot Size Owner's Name 504ATHEIW RCAF IC RPE. LitUf 5 Address FE34, Fle.,LIEWA5T. I-.A.?CA 1001 7 Contractor Re. EPtrQTlOJ Address P.O.ZoOS (101 Riz,ekiii...LE /540License No. 5' PM phorz.443) 424,- -17q I Phone 1.1119)7133 -9731 DESTRUCTION C1 TYPE OF WELL/PUMP: NEW WELL 1)4. )PLWELL REPLACEMENT LoEz_t_ 3 PUMP INSTALLATION CI SYSTEM REPAIR CI OTHER 6vizA0615, I DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity PKG. TREATMENT PLT. CI Distance to nearest: Well LEACHING LINE Li No. & Length of lines FILTER BED [I Distance to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS l 1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS II 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 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 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- Foundation No. Compartments Method of Disposal Property Line LI Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 Tracy 835-6385 Applicant datum ails pies to: vir2nTral4alth ermit/Services 1601 E. Hazelton Ave., P. Q. Box 2009, Stk., CA 95201 ra-M444AL EH 13.24 (REV. I 11 5 EH 14-26 FEE - INFO r ......,,,.......... V-X3Ersr AMOUNT DUE AMOUNT REMITTED -,- Kra CASH - RECEIVED BY U DATE PERMIT NO. CV 1 OD At- _b? ir .. ..- J1.---- 10 -9 -V7 ..,-, / 0-7-S?,52 +