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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 .:,'..1' t .... (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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,, ,, i.iviL 7.. .." 1 -, x . .a q 1- c D I size P- e i4A . ' Mcd",004.1.-. *Let Job Address k PM lence '7TS1 :349 ' Pe-64E4 ighone _ et- Owner's Name , . ,....-- Contractor's Name v,-A k- 171 cTovs. ---- License No ' 44c-7 0 7S Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT \G/ DESTRUCTION CI PUMP INSTALLATION D DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -----_ - -- . . - ! -t INTENDED USE 0 Industrial r; Domestic/Private El Public 0 Irrigation Repair Work Done Well Destruction Nurriber of living Jinitsi I Number of bedrooms i Character *soil to a depth i ' Water ta of 3 feet: • •--"----',ti.\2 Wble depth .. SEPTIC TANK .f; 1 CI 1T /Mf ypeg, L_._. ...i 1. CApacity ."-:1-- No. ComPartments I PKG. TREATMENT PLT., C 1. 4 i y f.1 f --,- Method of Disposal ' e. --- i Distariceito nearest: Well . . i 4 Foundation Property Line i i..../ 1 • --- ... '; I 1----tr-7-- &.1.-- i LEACHING LINE R 't ...0.714-o-. & Length of lines . f -1 Total length/size "4? f-142-C7:77- C Distance to nearest:14 i W II ' 7 ‘ k-- P-k Foundation Property Line 5.ertru`r N..,, '07 .-fer7Depth BP"-c- I- Sr ize -33 '1> ',Number e97f-e- 41 _ii: - Foundation ' - Property Line ....--* 33 ? —IA 71. sDa7 --... SYSTEM REPAIR LT OTHER El SEWER LINES --DISPOSAL FLD. PROP. LINE _ 0' Delta Depth of Grout Seal fyiae.isf:Grout --D Eastern —,-,--Surface Seal Installed by H.P. State Sealing Material (top 50') Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION, 0 REPAIR/ADDITION 1_1 DESTRUCTION C.1 (No septic system permitted if public sewer is Installation will aerve: Residence Cornmercial _ Other 1 available within 200 feet.) _ TYPE OF WELL - 0 Open' [3.2ttpth\ 0 Gravel Pack El Other Approx. Depth \ El Type of Pump • ITI Well Diameter Depth PROBLEM -AREA CONSTRUCTION SPECIFICATIONS 1 OylanteCl_ telExcavation Die, of Well Casing - Specifications Work Done - ' =1 Distance to neliest( Well., Signed Application Accepted by or Grout Inspection by cr) SEEPAGE PITS 1 SUMPS - I hereby certify that I have prepared this application and that the work will be done in ac-cordance with San Joaquin countyordinances, state laws, and DISPOSAL PONDS C . rules and regulations of the San Joaquin Local Health District. ' r 1 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 ofCalifornia." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this perrnieieissued, I shall employ persons subject tii Workman's compensa- tion laws of California." v. 1 . r .. . if ker i / The applic call for tuired in ctions. Complete drawing on reverse side. ' t 4, FOR DEPA MENT USE ONLY --- 7 — - -- - - -ALILC Area Date,. > --- - . Final Inspection by Additional Comments: El Stk 466-6761 0 Lodi 3E6-3621 0 rn2 DI fcy 835-6385 Applicant - Return all copies to: Environmental Haalthlbe 1 . 1i0gLiton Ave., P.O. Box 2009, Stk., CA 95201 FEE :INFO AMOUNT REMITTED CASH rzzi 3 -7 1-\ 1 t 4 RECEIVED BY DATE Ell 13-24 1REV. 10/831 "1:1 14-26 '\ PERMIT'NO. 2)___S- AMOUNT DUE