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APPLICATION. FOR PERMIT
<br /> SAN JOAQUIN�LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZELTON AVE.,,,STOCKTON, CA
<br /> Telephone (209) 466-67$1
<br /> PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED
<br /> n (Complete in Triplicate): ja tc. .
<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 Regulations of the San Joaquin
<br /> Local Health District.
<br /> Job Address _ � Gity���,-�•� .,�__ Lot Size- PM
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<br /> Owner's Name �52,� r �i 1 w .
<br /> Address Phone
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<br /> Contractor '6,10 /, lagc'_ Address e �YY. 11a�T,d ,Q License IN �`j Phone'"
<br /> TYPE OF WELL/PUMP: ;NEW WELL:❑ WELL REPLACEMENT ❑ DESTRUCTION ❑
<br /> i
<br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE 1
<br /> FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS
<br /> INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> ❑ Industrial ❑ Open Bottom _❑ Manteca Dia. of Well Excavation Dia. of Well Casing
<br /> CIDomestic/Private ❑ Gravel Pack--: ��-G7 Tracy �-_ Type of Casing Specifications'
<br /> ❑ Public ❑ Other y❑ Delta Depth of Grout Seal Type of Grout
<br /> ❑ Irrigation ..-..Approx. Depth ❑'Eastern �, t Surface Seal Installed by-
<br /> .' Repair Work Done ❑ Type of Pump ^H:P. State Work Done
<br /> Well Destruction ❑ Well Diameter. Sealing Material (top 50T'
<br /> �:..,_._..�.aM.,._._�.--�_._.�..�„-Depth------.____._.�..... ----=--F..iller-Material..{Below.r�0•.l_._�....w.,...�-_ .._.._-.»_ -� ,�_.�-�,
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION Ll (No septic system permitted if'public sewer]is
<br /> f # r r -available within 200 feet
<br /> Installation will serve: Residence Commercial_ Other f
<br /> Number of living units Number of bedrooms
<br /> Character of soil to a depth Qf 3,feet: i�A � - �: .__. -- Wate7 table dept
<br /> ~� `! 4�e.
<br /> SEPTIC TANK TypelMfgi• r Capacity Na: Compartrnents'�
<br /> PKG. TREATMENT PLT C Method of Disposal
<br /> i. Distance to nea�esf::"" ;VYeII eFoundation 141— Property Line ^ !
<br /> - t �• 1 ; ..., �—
<br /> LEACHING LINE ❑I' No: & Length of lines C �, Total length/size.C�D-r� `5 ✓ �� i
<br /> f Pro
<br /> FILTER BED Distance' Well nearest: �� i Foundation Property Line t
<br /> € SEEPAGE PITS ❑ Depth � Size Number
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<br /> r SUMPS _ 0 Distance.to neared:, ^^'Well F Founbati6h -Property Lin 1.
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<br /> P ! b
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<br /> DISPOSAL PONDS Ll
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<br /> I hereby certify that I;have p.repared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and
<br /> rules and regulations'of the San Joaquin Local Health.District.. ; 5
<br /> Home owner or licensed agent's signature certifies tFie-following: "I certify that in the performance of the work for which this permit is.issued, I shall not
<br /> employ any person in such manner as to'become subject Wworkman's compensation laws of.California."'Contracto'r's hiring oesub-contracting signature
<br /> certifies the following:"�certify that in the performance of the work for which this permit is'issued, I shall employ persons subjec6 to workman's compensa-
<br /> tion laws of California."
<br /> The applicant must call Jor all re red inspections. Complete drawing on reverse side. Y'
<br /> r 1 ' ��✓ � ', ___.,SN,fjMh�.F.. .fi"„A.,d,�'^e'�.M t,.e�-{Ro.^.ws.l. �ay F,;;.'/,� / +�._
<br /> Signed .Title: X Dater
<br /> i
<br /> FOR.IDEPARTMENT USE ONLY I
<br /> SAA. 51-211-106
<br /> Application Accepted by j i Date A f a � p
<br /> Pit or Grout Inspection by l S Date Final Inspection by Date
<br /> Additional Comments: -_ 1
<br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .
<br /> Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201
<br /> j.�'..,+�--........y,.._._...—.FEE� d CK
<br /> INFO AMOUNT DUE AMOUNT REMITTED CASH Ay. RECEIVED BY DATE PERMIT NO.
<br /> + EM�1324.1RE1/..I.i.a.51-.o-..�. x f O,T,�,;,.".�..� - x,., _ •:.:tr xH-wr- »za�c..y.�..�.y� —»— -:sem• --�.
<br /> EN 14-28
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