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•r <br /> APPLICATION FOR PERM;, <br /> SAN JOAOLiK LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT N0. `;?"1— <br /> Telephone (209) 466-6181 DATE iSSUEO �s <br /> PERMIT ExPiRES 1 YEAR FROM DATE ISSUED <br /> ,s> (Complete in Triplicate) <br /> 2 Application is hereby made to :he San Joaquin Local Health District for a permit to Construct +"d/or install the work Herein <br /> described. This applic�:ion is wade in compliance with San Joaquin County Ordinance NO. 549 for sewegt or b. 1062 for weYt/psab <br /> and the Rules and Regulati s of the San Joaquin local Health District. <br /> Subdivisioc 11M <br /> 'Job Address <br /> Owner.s Name i Addrtss <br /> se No. <br />„rl�g Contractor's Name <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ <br /> : OTHER <br /> ;r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR I❑ <br /> DISPOSAL FLD.,w _ LINE <br /> 0[rT E TO NEAREST: SEPTIC TANK _ _ SEWER IINE9 SER WELL P1T5l5tlNPS <br /> `t' FOUNOAl,yl_ AGRICULTURE WELL ` <br /> TYPE OF WELL PR�SLEk AREA inTR4IGTION SPEC fIC-1 AT IONS- v V, 1' i <br /> 016. of Wall t"Awation <br /> Open Bottom ❑Manteca _ <br /> Dia. of well Casing �. <br /> L Gravel Pack ❑Tracy <br /> ►uDlit 0 Other ❑Delta { Type of Casino <br /> Lj Irrigation Approx. ❑Eastern Specifications <br /> ,y ❑Cathodic Protection Depth Depth of Grout Seal <br /> ❑GoophvsIca I Type of Grout — 1" <br /> ❑1.!htr Surface Seal installed by <br /> State Mork <br /> Repair .ark tone❑ Type of Pumv H.P. <br /> Jd <br /> Well Destruction❑ Well Diameter Selling Material (top 501) — F <br /> Depth Filler Material (Ile;W 509 — <br />_{ . TYPE OF SEPTIC WORK: NEW INSTA / REPAiR/AGDITION ❑ (No saga! Unk or seepage pi;el ,e Withipublic00 feet.) is; � p <br /> Installation will serve: Res'deneCommercial <br /> . �{ <br /> Number of 1 iinunits: <br /> vg _� hwnber of badrooms Lot site �D Qv 1 + <br /> 1 � Water table depth 740 <br /> Character of soil to a depth of J feet. ,, Capecity 4p 00 No. covartalnts .� <br /> SEPTIC TANK [ Type/Mfg <br /> Capacity Method of Disposal <br /> PkG. TREATMENT Pl T. ❑ TYDe/Mr9 Property Line <br /> SEWAGE SYSTEM ❑ Distance to nearest: Mall JrO <br /> Foundation <br /> DESTRUCTION <br /> ^ Total length/site <br /> LEACHING LiNE No. A length Of 111!6 �� .4 Property 11M <br /> FILTER $ED [3 Distance to nearest: Well <br /> Foundation t a> <br /> SEPAGE PiTS ❑ Depth a - Silt Ml6�er 7 ; <br /> Sl9 i Distance to naarestt, Well IF tic*��,� ProperV Line <br /> DISPOSAL PONDS �l <br /> I hereby certify that I neve preWred this application and that the work Mill be done in sccOrd+nce with San Joaquin co"ty <br /> o.dirarces. state laws, and rules and regulations of the San Joaquin local Health In theyWhich this <br /> Home owler or licensed +gent's signature certifies the following: •l eer►i•f that in the parfo"aance ofat���f� Calitomia.• <br /> ��ee+�++1t Is Issued, t 6n+t1 not aeyoley any parson to such emnner as to becr+m+ wbJ*Ctto fWkwil s!!igen a of stye work for which <br /> Caitracter't hiring or sub-contrectlnp signature certifies the following: 'T certifythat in the performenc <br /> this permit Is issued. i shall employ persons subject to workmen's comm"t4on laws of c41/fernla. <br /> The +pplNun st call fora equ ed inspections. Complete drawing on reverse`s1de. Cant f <br /> c r�i r Title: -- <br /> y` Signed X DEPARTMENT USE lY• j� ❑.Stk 466-6701 <br /> is .Application Accepted by A� -`�'-"""—" <br /> CI Lodi 369-3621 <br /> Additional Comments: •Y❑' Mantou 923-7104 <br /> Pit or Grout inspection by Ate ;/''`�Q� <br /> Ate (� Tracy. 835-6305 <br /> Final Inspectior by ham! P.O, Box M. Stk., CA 95201 <br /> lieltth Permit/Service+ 1601 E. H+telton Iwo . <br /> /1pp11cant - Return all copies to: EnrirormMU , <br /> [EC��E�;7AMOUNT REFIIttED RE EiVED BYLL1T� PERMIT N0.}y <br /> 10/82 $00 , <br /> FJi 13-24 REV. 10/82 , <br /> 14-26 r, <br /> h <br /> ,... r. -n...,,.«.,enk•..n...,•.-- ...... ,-'w�Im6ea7raAi3ttts' " -. _r,..,4 - -. , <br />