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APPLiCATION FCz PERMIT <br /> SAN JOAQLIN LOCAL H_,AL TH DISTRICT <br /> 1601 E. HAZELTON .AVE,,,_.STOCKTON, CA PERMIT NO, 73 2-S 7 <br /> Telephone (209) 465-,6781 <br /> DATE ISSUED -�� <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplica%e) � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local yHe�al�thyy�istric C� <br /> Job Addressp��, � d�MBK $f Qf/�Subdivisio Name <br /> Owner's Na Address S Phone <br /> Contractor's Name :,��G�icense No. Phone%Z: _ z316� <br /> TYPE OF WELL/PUMP 14ORK: NEW WELL`���❑ WELL REPLACEMENT ,rDESTRUCTI U <br /> PUMP INS - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fl-D. PROP, UINC <br /> FOUNDATION AGRICULTURE WELL OTHER WE L; RITSUA <br /> S <br /> INTENDED USE T EL�1L 15�, WAaA-Z ____X-WtJST3UCTIO 4TIONS <br /> I findustrial U Open Bottom F-1 Manteca Dia, of Well Excavation <br /> Domestic/Private Gravel- "a Pia. of Well Casing <br /> Public Other Delta Type of C ng � I <br /> Ljirrigation Approx. E] Eastern <br /> D Cathodic Protection <br /> Depth Specifitat ons <br /> Depth of G out 5 al <br /> n Geophysical - i <br /> Type of Grout <br /> U Other Surface Se 1 Ins ailed by _ *` }•,� 4'\ <br /> Repair Work Done ❑ Type of Pump H.P. State Work DoneITIA <br /> J� <br /> Well Destruction U Well Diameters` Sealing Material (top 501) <br /> Depth Filler Material (Below 50') �� . <br /> TY OF SE TIC W NEW I�S`TALLATION REPAIR/,ADDITION (No septic`tank or se page pit l sew <br /> Ins anon wi l serve: Resident" - 'rl5munercia I Other <br /> Number of living units: Number of bedrooms Lot size, <br /> Character of soil to a depth of 3 feet: Wate �epth ' <br /> SEPTIC TANK Type/MfgCapacity - r�V7tij, omes , <br /> PKG. TREATMENT PLT, Type/Mfg CapacityMa iod� abt3 o�saI <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation �erty Line <br /> DESTRUCTION 4 ! <br /> LEACHING LINE u No. & Length of lines Total length size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Numbe1 <br /> SUMPS U Distance to nearest: Well Foundation Property Line 1 <br /> DISPOSAL PONDS <br /> I <br /> I hereby certify that I have prepared this application and that the work-will b done n accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Heal h Dist ict. <br /> Home owner or licensed agent's signature certifies the following: "I certify th t in t e performance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become sub ect to workman§ compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I ce tify t at in the performance of the work for which <br /> this permit is issued, 1 shall employ persons subject to workman's compensation laws o California." <br /> The appl , t must call for all required inspections. Complete drawing on rev a sid <br /> Signed X Title _ <br /> MENT ONLY <br /> Application Accepted b Area Q� <br /> Additional Comments: v Lodi 369-3621 <br /> Pit or Grout Inspection by AIIA Date �j Manteca 823-7104 <br /> Final Inspection by Date ?9--- L Tracy 835-6385 <br /> Applicant - Return all copies to: Environ ntal Health Permit/Services 1601 E. Hazelton Ave., R.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY :' I1ATE PERMIT NO. <br /> INFO <br /> l <br /> O <br /> EH 13-24 REV. 10/82 r f f IO/82 r00 Q Q <br /> 14-26 r�� "' " vUs I D�Jr Wo �W4-5 do <br /> 17-5`f �o o r V , <br />