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SEEPAGE PITS-.., SUMPS DISPOSAL PONDS Depth Size Number - 7 Distance-to nearest: Well Foundation 142 Fe" —*637"717115i7--4 , . EN 13-24 REV. 0/82 14-26 Signed X 10/82 b00 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-5781. RMTI EXPIRES 1 YEAR FROM DATE ISSUED ;Complete in Triplicatee PERMIT NO. 3 - 9 DATE ISS0F0 -7 Application is hereey mate to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TniS application is made in tomo'Ilence with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and tne Rules and Regulations of the San Joaquin Local Health District, Ej Delta 0 Eastern Type of Casing Specifications Depth of Grout Seal Job Addres PROP. LINE PITS/SUMPS DESTRUCTION uji OTHER' 0 DISPOSAL FLU. OTHER WELL WELL .EPLACEMENT SYSTEM 'REPAIR' SEWER LINES AGRICULTURE WELL TYPE OF WELL/PUMP WORK: NEW WELL PUMP INSTALLAiI0i DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION , Subdivision Name Phone d.,,• 2 z Address nil, 'cense no. Owner's Name Contractors Na INTENDED 'JSE ri Industrial , Ccvaist,ecePritate- Publ ic. Irriglitcon?" ' Cathodic Protection 0 Geophysical Other PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Manteca Die, of Well Excavation Tracy Die. of Well Casing Type of Grout Surface Seal Installed by I.P. State Work Done Sealing Material (top 50') 7111er Material (Below 50') TYPE OF WELL E Open Bettoil — Gravel Peck D., Other Approx, Depth, N Li (No septic tank or seepage pit permitted if public sewer is , availatle within 200 feet,) Other Repair Work Done 0 Type of Pump Well Destruction (et Well Diameter _ Depth TYPE OF SEPTIC WORK: NEW INSTALLAT1 Installation will serve: Resi hereby certify that I have prepared this apolicatioe end-that the work will be ;done in accordance with.. SanJnaquie county ordinances, state laws, and rules and regelations of tAh San)Joaquin Local Health District. epee owner or licensed agent's signature certifies the following: "I certify that in the perforeance of the work for which this permit is issued, 1 shall not employ any person in such menner as to become subject to werkeent compensation laws of Celifornia." Contractor's hiring or sub-contractino signature certilies the following: I certify that in the performance of the work for which this permit is issued, I shall emplcy persons subject to workmen's compensation laws of California." The appllc.trestca1i1r ii required inspections. Complete drawing side. • OR DEP Date Date Wealthe it/Services 1601 E. IEEE INFO BASE N!OUNT fleE AMOUNT REMITTED RECEIVED BY DAT: PERMIT NO. 1 (01,9 1 Pit or Grout Inseecti Final Inspection by Applicant - Return all copi to: App atlo#i cceptee by Additional Comments: ,X Lodi 369-3621 "Manteca 823-7104 171 Tracy 835-6385 azelton Ave., P.O. Box 2009, Stk., CA 95201 Stk .466-6781 4 c:01) —S> eee • -3 ozS USE ONLY . Area 0 Number of living units: i/ Number of bedrooms _5 Lot size __selgeed.4e. Character of soil to a depth of 3 feet: ;heel F4---- Water tanle depth 1.14414,..r. SEPTIC TANK 0 Type/Mfg Capacity PKG. TREATMENT PLT. 0 Type/Mfg e, A, Capacity SEWAGE SYSTEM Distance to nearest: Well Foundation DESTRUCTION 0 _ ^ No. Compartreets Method of Disposal Property Line LEACHING LINE Li No. & Length of lines • Total length/size Foundition e Property Line FILTER BED 0 Distance tc nearest: Well