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SEWER LINES DISPOSAL FLD. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or irsta 1 the work he described. This application is mace in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules nd Regulations of the San Joaquin Local Health District. F 114E, ki_-) Job Address Subdivision Name - /a (040-1/ot) TYPE OF WELL/PUMP WORK: NEW WELL PUMP INSTALLATION i DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION WELLKREPtACEMENTtlii DESTRUCTION SYSTEM REPAIR ""E • OTHER E AGRICULTURE WEL-1!"7 "a: OTHER WELL PROP. LINE 1 PITS/SUMPS INTENDED USE 1 Industrial Domest-ic/rt=tvale a Public Li Irrigation '0 Cathodic Protection J Geophysical ,F1 Other 1 Repair Work Done n Type of Pump H.P. Well Destruction Lj Well Diameter . iSealing Material (top 50') ._ Depth.: 1 Filler Material (Below 50') ! TYPE OF SEPT:C INSAL TI.Q4pcp/RIPAIh/ADDITION 'Lj (No ; Installation will serveesidence :_..e '..commercial _i Other i Number of living units: _ 1 Number of_bedrooms i Lot size f 3 feet: 1 M Character of soil to a dept o - °g-E'•.-' , 1.7?'"No. 8 Length o7f lines 6s. - Li Distance to nearest: Well _0400 1 Foundation TYPE OF WELL üOpen Bottom _D Gravel E Other \ Approx. Depth Pack Tracy Delta ,. Eli ia1Zrn PROBLEM AREA Manteca CONSTRUCTION SPECIFICATIONS D1Ti--0-Well -Txcavation Die, of Well .Casing of Casing Specifications Depth of Grout Seal Type of Crout Surface Seal •Installed by State Work Done septic tank or seepage pit permitted_if public sewer.is available within 200 feet.) ' 1 SEPTIC TANK . PKG. TREATMENT PLT. ' SEWAGE SYSTEM 1 DESTRUCTION LEACH-ING LINE I FILTER BED 6?- Type/Mfg (1,0 0(LVe. / .Capacity E Type/Mfg Capacity - Distance to nearest:-Well __sly...-. Foundation --T- Total length/size I 1 0 , ,/ 'Water table depth I *I.,- :No. Compartments , J Method of Disposal Property Line 2,-C f Property, Line 5-0' SEEPAGE -PITS 4 SUMPS , 1 DISPOSAL PONDS ordinances, state laws, and rules and regulations of the SanlJoaquin Local Health District. Home owner or licensed agent's signatureicertifies 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 workrianN compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for wnich emit is issue I shall em loy persons subject to workmans compensation laws of California." I hereby certify that 1 have prepared this application and that the work will be done in accordance w1th-5in-1Y y uuo..7 Ceoth 1 a 4r . Size 330 LI Distance to'nearest: Well Lie , Foundation 0 • f Number !. • ,/ /- Property Line _ 1 i The applic ,Signe Ail ''' Title: USE ONLY Application Accepted bye.. Area OS__ ›-i-1 Stk Additional Comments: ',L....4 ci Lodi 369-3621 ! Pit or Grout Inspection b el' r Date ii.,7-gf, u Manteca 823-7104 Date gal:12_ fp Tracy 831-6385 Final Inspection by Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA -t ---S •e----7--4-7Z -' :-.---:: 9 ' REV. 10/82 10/8271- uireTIKEljns. Complete dra ing or se sid 95201 FEE I -BASE .AMOUNT, DUE ' AMOJNT REMITTED RECEIVED BY DATE PERMIT NO. INFO, t' 9''' C L-4 I-11-z--a- 3 _g_i3_P-.3 I EH 13-24 14-26 , Owner's Name: 'Dontractdir'S -Narrie t2V Wit k_License No. PERMIT NO, DATE ISSjED 11 - 7--X3 APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH plSTRICT 1601 E. HAZELTON AVE.: S-OCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. , (Complete in Triplicate) • 3 . . Address - 4— 9 P-56, Phone Phone