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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PER_PAIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San.Joaquln Locsl Health District for a Permit w 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 {.� � C;ry <sP/ _ Lot Size--- <br /> LG-4�P3M <br /> 0 � Address 37,4iff'rf—C Phone-, <br /> Owner's Nam.a —. <br /> 3r7y <br /> Atlbress License No.yPhanP <br /> Contractor Fid Yn LJmoD / l <br /> TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT C DES,RUCTION ❑ <br /> PUMP INSTALLATION CI SYSTEM REPAIR ❑ OTHER C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD.__ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL--- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> "— Dia.of Well Casino <br /> F.1 Intlustriel O Open Bottom CI Manteca Dia. of Well Excavation <br /> C1 Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I.1 Public Cl Other fl Delta Depth of Grout Seal __-_ Type of Grout_ - <br /> A vex. De llr I 1 F.astorn Surface Seal Installed by <br /> I I Irrigation — VI P 1 <br /> Repair Work Done U Type of Pomp H.P._ State Work Done <br /> Well Destruction i1 Well Diameter __. Sealing Material IMP 509 q <br /> Depth Filler Material 18alow 509 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ' OESTRUC'fIuN I 1 INo septic systam permitted it pubkc sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Z Commercial_ Other <br /> n Number o1 aving units _L_ Number of bedrooms___71— <br /> Character of soil to a depth 3 fear ._�+��-��-��'E' -- Water table depth <br /> SEPTIC TANK F 1,Type/Mfg rt0. Ra�YE '-�— Capaotty-12,d1c2_ No. Compartments Z <br /> PKG. THCATMENT PLT.LI / Method of Uispoaal <br /> Distance to nearese Well -l�0_ Foundation��.__ Property Line '7-f <br /> LEACHING Llf1E rPv No. 6 Length of lines _­r/—Q'd r .--- Total length/size ' X Z/ <br /> FILTER BED Ll Distance to nearest: WI_L7,rf Foundation lif? — ProWnY Line 7rz <br /> �// Number <br /> SEEPAGE PITS I✓ DepIM1 _ — /� a 7sl J <br /> SUatPS I I Distance to nearest: Well_I J�/' Foundation -4_ Property Line <br /> DISPOSAL PONDS a <br /> hereby certify that 1 have prepared this application end that the work will be done in accordance with Sen Joaquin county ordinances,state laws,and <br /> rules and ragulahons of the San Joaquin Local Health District. I shelf not <br /> Home owner or liconsod agent'a Signature renlFNs the fntiowing;"I certify that in the performarR'e f the work for which this permit L vactin, <br /> employ any person in sur.h *^,:,m ,a to bocorna subject to workman's compensation laws of Calif^rnia."Contractors hiring or suDcunnacting signature <br /> certifte•Th-rCl....mg.'9 comfy trial in the performance of thn work for which this permit is issued,I shatl employ persona subject to woAman's compensa <br /> Sin taws of California," <br /> The applicem Most call for NI required inspections Complete drawing on revanie side. <br /> f-- <br /> Sipnod _ Titto: �- Date: <br /> FOR DEPARTMENT USE ONLY <br /> _ � Date4 � — Area <br /> Apppcation Accepted by _ - s�--j—�%� <br /> xx / <br /> Pi or Grout Inspection by <br /> Daln/'�)_u.�- Final Inspection by - - x--f----h- <br /> Additional Comments: <br /> ❑ SIk 4666781 C Lod, 3693b21 CI Manteca 823.7104 Cl Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1501 E, Hazelton Ave.. P.O. Box 2009, SIk., CA 95261 <br /> �iEE %a REUt'VED BY DATE PERMIT NO. <br /> FO AMO/UNT DUE AMf]UNT Rf MITTFp 4ASq�/ J) J( <br /> FN I)1.1RFV /n-(l G'h G7 ✓ <br /> FN Ia.}a <br />