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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IbOI E. HAIELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6181 t <br /> 1 <br /> PERMIT EZPiREY 1 YEAR FROM (,ATC ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> Atpli'.atlos is hereonr made to the San Joaquin Lout Health District for a permit to construct and/or install tha "Tort herein <br /> descr bed. This application Is made to compliance with San Joaquin County Ordinance he. 549 for sewage or No. I86Z for well/pup <br /> and tae Rules and Rpulati n► he San Joaquin 1 ealth District. <br /> .qb A'dres% Subdtvlslon Name <br /> Ovler's Name Address _ _�tA�+r►�L. Phone t✓.1 <br /> Cpnt►Ictor'► ha r License No. i 2 1�(� Phohr <br /> 11�_E Of MELS/PUMP WORV; NEW WELL (] WELL REPLACEMENT [] DESTRUCrmi o <br /> AP PIMP INSTALLATION 0 SYSTEM REPAIR O OTHER 0 <br /> 01ST1MCE TO NEAotSTs SLPiiI' TANr SEWER LINES DISPOSAL FLD. _ PROP. LINE <br /> `- IOIaIDATA M AGRICULTURE WELL OTHER "LL �- PITS/SUMPS <br /> Leo�L -TYPE F WELL P!MLEM AREA COMSTIKXTION SPECiFICATiONS <br /> D indw trial p Open bottom p menteca Dia. of Well Excavation <br /> [inomostic/Priveta Gravel Pack (�Tracy Dia. of Well Casing <br /> Public Cj Other p Del to <br /> [, irrigatlon Approx. p Eastern Type or Citing _ <br /> [J Cathodic Pretaetion Depth Specificat/one _ <br /> I_! <br /> ~YS lta) Depth or Grout Seel - <br /> �J <br /> Type or Grout other Surface Seal Installed by <br /> Ilepair Work Dow D 1YPe of pump _. M.P. State Bork Done <br /> WP17 DestrsRtion(] ValI Diameter —SM11nq Material (top 601) <br /> Depth Filter Material (Below 601) �---- <br /> TYPE OF SEPT.0 I!)Ikl: NEW 100ALLATION 0 IUPA111/AWI110N No septic tank or seepage pit pormittcd if Puullc sewer is <br /> available within 100 feet.) <br /> installation will terve: Rastderice _ CoaamerNa) ✓OtMr <br /> Number o/ living units-, be <br /> Numr Of roomy Lot bite <br /> Character of soil to a depth of 3 feet Water table Jupth <br /> SEPTIC TANK �j Type/Nfg Capeclty No, cumpartnrnts F _�— <br /> Pr.G. TREATMENT KT. 0 type/Mi9 Capacity Melhid of Ulsposal <br /> Distance to nearest: Well Foundation Property line _ c. <br /> i <br /> LEACHING ZINE U No. & Length of ilnel ')tai length/file <br /> FILTER BED D1.tance to nearest: Well Foundatlun Property Lino _ <br /> SEEPAGE PITS [ Depth - Sile Mwbery <br /> SUMPS LI Distance to nearest; Well .4 t Fou dation __L- ti— Property Line r <br /> DISPOSAL PONOS [) <br /> turrfcl<aa <br /> aAilAaAtMaifaaonsTerraaae� <br /> 1 hereby certify that 1 have prepared this application and that the wnrk will be done In accordan.r• with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin local Health District. <br /> i+ure owner or licensed aylant's signature certifies the following: "I certify that in the parfurnence of the work for which this <br /> permit is issued. I shall not employ any person in such manner as to become subject to workman!rompensotion laws of California.` <br /> Contractor's fairing or sub-contracting sivi4ture certifies the following: "1 certify that in the pertormance of the work for which <br /> t�ls pRrmit :s issued, I shall employ pers.m s subject to workemn's compensation laws of California." a <br /> The applic must e f all required inspections. Complete drawindrawinq n�erse side. <br /> ♦ 3ned X •t_ Title: �� - ---- Datc: '-/0 - 3 <br /> FO DART EN USE ON <br /> App cation Accepted by �������Area ❑ Stk 466-6781 <br /> mmI <br /> Additional Coents: l� Lodi 3b9-3621 <br /> Pit or Grout Inspection by Date Manteca 823.7104 <br /> Final Inspection by P Date Tracy 8354385 <br /> plicant - Return all copies to: Environmental 4ealth Permit/Services 1601 E. Hazelton Ave., P.O. ea,e 2009, Stk., CA 95201 <br /> FEE�BASE AMOUNT DUE AMDUhT REMITTED RECEIVED BY DATE PERMIT N0. I <br /> INFO } <br /> 13-24 REV. 10/8? 10/62 500 <br /> 14-26 t <br />