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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL-ON AVE., STOCKTON, CA <br /> Telephone (209) 466 6781 <br />.y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cornplet� in Triplicate) <br /> y` Y Application is lweby mauc <br /> de to the San Joaquin Local Health District for a permit to construct and/a install the work herein daseri�d•TI1M appaeatlon ra <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wolf/pump and tM,Rules and Reguiotions of the San Joaquin <br /> ' Local Health OisuictPM. <br /> n c y� <br /> Job Address 15-11-414 — Esea Ion �ej1da ��_ City JC 6 1 Lot Stat <br /> �S a <br /> 5 SC0.�01'ti P11om — <br /> Owner's Name Address <br /> Contractor-D-1 1J Address _License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ <br /> PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISfbS71L FLD PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION$ i <br /> ❑Industrial Ll Open Bottixn ❑ Manteca Dia. of Wel ExciJi", Dia,of WM Casing <br /> 1 ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of <br /> 171 Public n Other n Delta Oepth of Grout Seal T` c — <br /> I'I Irrigation _.Approx. Depth I I Eastern Surface Seal Insglad dy <br /> Repair Work Don--. U Type of Pump H.P. Stall Work Dom <br /> I � <br /> 4 Well Destruction F! Well Diameter Sealing Material Itop 50'1 <br /> a... Depth Filer Material Mallow 50') <br /> TYPE OF SEPTIC WORK. NEW INSTAL lfc REPAIR/ADDITION 1 I DESTRUCTION I I INo atpsyuwn M pubNc ttwM M <br /> r avalablts within feet) <br /> i Installation will serve: 9esidence_ ConnrttrcMl <br /> Number of living;units: —L Number of bedrooms <br /> vftt <br /> Character of soil to a depth of 3'faat: ��~daP� <br /> SEPTIC TANK {IType/Mfg COP-111Y746-10VNO'Comptrt�rtallta <br /> PKG. TREATMENT PLT.❑• t r—, <br /> Distance to WSA Fan+dation Ply Lk* <br /> i <br /> LEACHING LINE ❑ No.8 L of*M T9taI Mngth/ai:t j <br /> FILTER BED 19 Distance to ON~: " Will! /e' - Foundation-sem---+- P<o0ety Lire VIXS <br />> SEEPAGE PITS 1" Depth Si�e N �. <br /> 1 SUMPS 1.1 Distinct*to tbanst: Wim /Aft" 1 Foundation— :- PtoptRy Lim <br /> f � � D15PC SAL PONDS n { 7,/�' � <br /> 1 hereby certify that I have prepared this applcation and that the oak wig be date in alxadand wit►+San Joaquin county <br /> atdnMcea area laws.and <br /> rules and regulations of the San Joaquin L"Health Diskrkt. <br /> PP` Hort+s owner or licensed egent's signatvrt M�folawirtg:'i car that In"lWformw j of tfia oak fa WAd Ills I Is Wouied,1 shat not <br /> employ any person in such manner as to become subject to vm*man's eornpansiodon Moa of Contraetor's aur oont►actMq alplthnt <br /> certifies the following:"I certify that In this performance Of the work fo�vwfllth tftM pttwtetlt leitlrind�imploY pMsor�a^,�wON%man*s em gm <br /> tion laws of California." <br /> T must call for all required .Complete drawNtg Itsllafaa ( r T <br /> ig� ! <br /> I 4T USE O:/LY <br /> Nt Om -r� ' Area �± <br /> Application Accepted by _ r <br /> Date <br /> Fkuei Inspaotlon by Ot1a — % <br /> j Pit M Grout Inspection by - <br /> iAdditional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3821 ❑ Manteca 823.7104 O Tracy 036•e308 <br /> 1 Applicant- Return all copies to: Environmental Hearth Perrttlt/Services IWI E;Hare ton�Aure., P.O.Sar 2000, Bek..CA tI201 t <br /> i <br /> FEE AMOUNT OUE AMOUNT 111MITTlO I ower[o By OATS fMAMR NO. c . <br /> T7w 31 <br /> • EH 142a <br />