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APPLICATION FOR PERMIT <br /> ,� SAN JOAQUINLOCAL HEALTH DISTRICT <br /> ZF <br /> 1601 E. HAZE'"T644AVE., STOCKTON, CA <br /> Telephone (209) 466-V6i <br /> PERMIT EXPIRES VYEAR FROM-DATE 'ISSUED <br /> t VN.. 4 <br /> (tom"p-le-tp, in, Tr,ip'lidate) <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regula.tions of the San Joaquin <br /> Local'Health District. ,'::" <br /> Job Address _4,1 rstu, tk&rf Ct-di 94 k 1 -1-3 P,M <br /> city ze <br /> Owner's Name _CLft Wris_11N d GvriAVWJ Address <br /> :-Phone <br /> Contractor License No. <br /> " Phone <br /> I <br /> WELL/PUMP: Address 0%,�AE -NEW El WELL REPLACEMENT 171 DESTRUCTION C <br /> PUMP <br /> INSTALLATION El . SYSTEM REPAIR El OT <br /> DISTANCE SEPTIC TANK SEWER LINESDISPO. PROP. LINE <br /> � <br /> FOU -AGRICULTURE WELL ;,- <br /> �HER WELL PITS/SUMPS <br /> INTENDED USE. TYPE OF WELL - PROBLE UCTION SPECIFICATIONS <br /> C1 Industrial—, El Open Bottom 0 Mant Dia. _o1_�e <br /> Dia. of Well Casing <br /> 11 Gravel Pack racy Type of Ca <br /> 0 Domestic/Private f C ingSpecifications <br /> 0 Public El Other 0 Delta lo Depth of Grout Sea] Grout <br /> El Irrigation pprox. Depth El Eastern <br /> Surface Seal Installed by <br /> Repair Work Do Type of Pump H.P. State Work Done <br /> Well D tion E Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Wterial (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION 0 DESTRUCTION D (No septic system permitted if public sewer is <br /> -I' X I .. T available within 200 feet.) <br /> Installation will serve: Residence V Commercial— Other <br /> Number of living units: __t__ Number of bedrooms Z <br /> Character of soil to a depth of 3 feet: 1-0 AAA Water table depth <br /> ivx_� <br /> SEPTIC TANK V,Type/Mfg em Am tj Capacity FPSL No. Compartments <br /> PKG. TREATMENT PLT. n 1 4 rPA LA.* +�em &&kdosp.sal <br /> Distance to nearest: well Foundation— Property Line <br /> LEACHING LINE �No. & Len <br /> gth of lines Total length/size <br /> FILTER BED 1-1 Distance to nearest: Well Foundation_ Property Line <br /> SEEPAGE PITS [B Depth ID -_SiZe _ Number <br /> 656`MP Distance to nearest: Well Foundation Property Line— <br /> DISPOSAL PONDS [D <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thig 'permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation'laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the�4 - I . t <br /> J9,wirng_.""I ertify t in the performance,of the work for which this permit is issued, I shall employ'p6rsion�§subject to workman's compensa- <br /> tion laws J f.ni, <br /> a owing: rtify t <br /> r I <br /> f or <br /> nia <br /> ust cal <br /> a <br /> The appli n ust cal r fired inspections. Complete drawing on reverse side. <br /> Signed "nr . r - - - _1 .'. - r—< &S'�' <br /> V Title:L Date: <br /> DEPARTMENT USEONLY' - <br /> .b k�= � Diie 60Application Acc 77 ' <br /> y Area <br /> Pit or out Inspectionbya�^Date (0_0W_46 <br /> A Final'Ini by QCL�A--C Date <br /> Additional Comments: <br /> 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-710'4 ❑0 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services160i—E. Hazelton Ave.",'P.O. Box 20D% Stk., CA 95201 <br /> FEE AMOUNT DUE )0 AMOUNT REMITTED <br /> INFO RECEIVED BY._ DATE -PERMIT'NO. <br /> + EH 13-24 CREV.)/B 5) <br /> EH 14-26 g5 —ko 072 <br /> -4. <br />