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M <br /> � t' <br /> :1 APPLICATION FOR PERMIT �J- .� <br /> ' l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone{209) 46781 <br /> t : PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) r � r <br /> w S ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orWMAthe work look deserbad <br /> made in compliancewith San Joaquin County Ordi nce No.599 for sewage or Na.1862 for weNl pump and tits Rinse and Regttlatbrts * _ N:OX'£ <br /> Local Health District, <br /> } 5 <br /> Jab AddressS,dT city I <br /> l�g .v /�� lle Lot Gte Zv <br /> Address /G/y /f►!Pw/ '� •Y `�' <br /> Owrler'a Namara v. <br /> 'r Address <br /> dress_ License Nora <br /> Contractor DESTRUCTION ❑ <br /> 'Y TYPE OF WELL/PUMP: NEW WELL P, WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> o DISPOSAL FLO.,.,,_^,.PROP LINE `� � , <br /> r SEWER LINES ��� ,A h r ' <br /> DISTANCE TO NEAREST: SEPTIC TANK ��b�� OTHER WELL.—.- <br /> 'Y <br /> ELL. PITS/SUMPS y A axes <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C]Industrial Q Open Bottom �Manteca Die.of Wall Excavation R -�— <br /> Dia..of Well <br /> Type of Casing,�+ r t T Spseifk atlors ` <br /> IR DomesticlPrrvate ❑Gravel Peck Q Tracy <br /> G Public Cl Other GJ 13eha Depth of Grout Seal TY1w + <br /> fgpprox. DeptAf <br /> h ❑Eastern �^u ace Sea!Installed by F <br /> Q Irrigation � / <br /> A � H.P. Z State Work Dane fr . <br /> Repair Work Done 0 Type of Pump +. r , <br /> Sealing Material(top 50'}. <br /> Well Destruction Q WaEI Diameter ��___�- <br /> Depth Filler Material,(Below 501ic- <br /> 7YPE OF SEPTIC WORK: NEW INSTALLATION. REPAIR/ADDITION❑ OESTRUCfION s�elabh within 200 `em pwmnm If b_pc'� ; <br /> Z. Installation viol)serve: esidance Commercial Other h Rom fi> <br /> Number of bedrooms <br /> Number of Irving un'ns: Water tattle depth <br /> Character of soil to a depth of 3 F-1111111%11111 1111 <br /> kF i <br /> :! r Ca 6.�. ':No Compartments y, f <br /> SEPTIC TANK :" ❑ Type/Mfg Method`of Dhposa! } <br /> PKC,TREATMENT PLT.Q r I ° rf ° � <br /> a Distance to nearest: p oundation �- ProP�Y Lino '� M <br /> w <br /> 3 LEACHING LINE ❑ No.8 Length of IFnes T lengthlsixe i <br /> otal <br /> r <br /> FILTER BEd ❑ Distance ton t: Well! � -- : atiom ®6 Property Line � �`� „ fr: <br /> Number , <br /> • } SEEPAGE PITS ❑ th Size - i <br /> Line <br /> r' �} Distance to nearest: Well Foundation <br /> SUMPS r v <br /> DISPOSAL PO CI <br /> I hereby certify that I have prepared this application and that the work will be,done in accordance with Sen v uln county otdl+nantatsI�►a <br /> I hereby <br /> regulation;of the San Joaquin Local Health District. is 4sued�f�sitall <br /> Home nd re ulaticeflsed agent's signature certifies the fonowing:"I certify that in the performance of the work far whkh thje permit <br /> employ any person in such manner OPt <br /> as to become subject to workman's compensation laws of Cat'dl sFla 1 empfaSripe ons subject to <br /> certifiias;he foljovving:"I certify that in the performance of the work for which this permit is issued. v 1 <br /> iron laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side• <br /> ri Oatc <br /> tee "�L <br /> Signed Title <br /> FOR DEPARTMENT USE ONLYrT ar ti <br /> Date , <br /> Application Accepted by _ vP� <br /> {� <br /> r✓l{�W )- - InaPinspectionby D <br /> Pit or Grout Inspection by <br /> Date <br /> Additional Comments: 935.6385 r F Mfr <br /> ❑Stk 4666791 0 Lodi 369.3621 Manteca 623.7104 Q Tracy` { <br /> Applicant-Return all copes to:.Environmentai ea PermklServices 1BD1 E. Hazekon Ave.,P.O. Boat 2008 Stk.,CA 95201 r <br /> FEE AMOUNT DUE AMOUNT-REMITTED �9Hr RECEIVED BY DATE PERMR NO <br /> INFO <br /> •EH 13.24IREV-1'e97 <br /> E4147a - - + <br />