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APPLICATION FOR PERMIT <br /> R+ 4 Jr Irn, fta <br /> SAN JOAQUIN 'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> Telephone (209) 4666781 <br /> PERMIT EXPIRES l'YEAA'FROM DATE ISgUEdn <br /> lCbmplei6 iinfiiplicat6i ; <br /> fIT 11.,t! -,V:; <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here'in described. This-application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RLjles. and Regulations of the San Joaquin <br /> Local Health District. d­j 1�,_ <br /> r <br /> Job Address Al, t C, Lot Size PM <br /> Owndr '0 <br /> 's Name &XmOy =Phone 31/1 <br /> Add 19(� , <br /> Contract212 Address `7 C� " License No7;Zk Ra Phon,149- <br /> - <br /> TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT 0 DESTRUCTION E] <br /> PUMP INSTALLATION 1:1, SYSTEM THER-0_ <br /> DISTANCE TO NEAREST: SEPTIC SEP-�CiANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial 0 Open Boftom 11 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> • Domestic/Private 0 Gravel Pa I ck 13 Tracy Type of Casing Specifications <br /> • Public El Other 0 Delta Depth of Grout Seal Type of Grout <br /> • Irrigation ____Approx. Depth 0 Eastern Surface Seal installed by <br /> Repair Work Done Ll Type of Puip H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC,WORK: NEW INSTALLATION 29r' REPAIR/ADDITION L DESTRUCTION El {No septic system permitted if public sewer is <br /> i <br /> available-within 200 feet.) <br /> Installation will serve: Residence <br /> Co:mfiriercial,— Other <br /> Number of living units:__L Number of.'bpdroom 1-2 <br /> Character of soil to a depth of 3 feet- �Water table depth <br /> SEPTIC TANK IE- Type/Mfg Xe"_ Capacity aO6 No. Compartments, to <br /> PKG. TREATMENT PLT. El IV Method of Disposal' <br /> I <br /> Distance-to nearest: i WeII1100 Foundation &W Property Line <br /> LEACHING LINE n No. WILdrigth 6f 4ines Total len'gth/siie <br /> FILTER BED � E Distance to nearest: Well ALI,.F'o'u'-n d t i - Property Line <br /> SEEPAGE PITS 9 Depth IRS' 7-1 Size'—' Number <br /> SUMPS 0 Distanlle to nearest: Well ift IS-6 ,Foundatibn Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify f6at..1 have prepared this application-and that the'work will,be done in accdrdance'with San Joaquin county ordinances, state laws and <br /> that performance o "il <br /> rules and rag ulations.of,tqe Sin Joaquin Lodl,Health District. I <br /> Home owner or licensed"-a'g'e'nt"s,si'gna-tu'i�e ceriifi;s.the folGwihg: "I certify �i`nth�apb or, of-the or which this permit is issued' I shall not <br /> as to 6(16iiict to compensation lawsof Contracto <br /> 4, r',9 hiring or sub contracting signature <br /> employ any person in such manner mp California:' <br /> certifies the follo'ih -1'certify,that in't6e perfo'rmanc'e of the work for which this permit is issued,-[shall"play p6rsons_subject to workman's compensa- <br /> tion laws of California." '"t <br /> . 1 — ' <br /> The applicant. St Gall for II reqUir L'as-Ztti�,�n,.inspections:"Comp -drawing on Ireverse si <br /> U. plate IN <br /> Signed :Title: Date:,'Y aZ411 <br /> .j V'4t f — ----- <br /> FOR DEPARTMENT USE ONLY-J <br /> J, <br /> Application Accep6d by A�,. Dat Are, <br /> b <br /> Pit or Grout Inspection I�y Final nal Inspectionby Date <br /> Additional Comments. <br /> 0 Stk 466-6781 ;13 Lodi 369-3621 El Manteca <br /> - - - _823-7104 0 Tracy 835-6_385 <br /> . <br /> Applicant- R46irn alPop[as to: Environmental Health Permit/Services—601 E. Razal� n,Ave., PO. Box 2DO9,.Stk., CA 95201 <br /> rA <br /> CK <br /> "INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ME CASH CEIVED BYDATE <br /> _ <br /> �j , <br /> -24(REV <br /> +EH 13 1/851 <br /> EH 1428 <br />