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�jr �xtrn <br /> Y � <br /> � M�TvL'r1LRT1 7e 3ff� <br /> r t.. 7;?r..r ;.. >.x* Mr "+.�•t ;?^,.r..;e^•, r.._.,:rn*,.,.�+>.ra,,..u..�,+a-,w..,t+�'ro •�,s <br /> APPLICi.TION FOi'. PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y f� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �? <br /> Telephone (209) 456-6781 zap` <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �p <br /> e. (Complete in Triplicate) <br /> spa <br /> Apprication K hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein Ges awd'This appFiCaliotn I! <br /> 1713113 in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rufen and geputatians of tM San <br /> 1713113 .losquMt_ <br /> Local Health District, r € { <br /> r .r <br /> Job Address , Cite Lot SizeOwner's�a 11,16 7 _ <br /> Address D _ Phoneme Y � ) <br /> Con ,_ Address ���,/lam 7(_1e,/ ( �/' License No.�3Q2KP�726 Phone <br /> TYPE OF WELL/PUMP:..:, NLW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ° c; <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �`` � '• <br /> DISTANCE TONEAREST:`SEPTIC TANK SEWER LINES DISPOSAL FLD PROP._LINE <br /> FOUNDATION AGRICULTURE WELL- OTHER WELD_ PITS/SUMPS. <br /> INTENDED UGE TYPE OF WELL PROBL2.'.1 AREA CONSTFUCTION SPECIFICATIONS <br /> x <br /> O Industrial ❑Open Bottom O Manteca Dia.of Well Excavation Dw of Wag,' - <br /> t„asirip3 <br /> ❑ Domestic/Prvate C1 Grave Pack ❑Tracy Type of Casing_ Speaf-ieatlomS <br /> f 1 Public y t' is Other F 1 Delta Depth of Grout Seal Type d <br /> i <br /> I I Irrigations j ---Approx. Depth I I Eastern Surface Seal Installed by t <br /> Repair Work Done L] Type of Pump <br /> H.P. _ State Work Dorsn-1 <br /> t ' <br /> Well Destruction ❑ Well Diameter Sealing Material(top 50') _ y, <br /> tf <br /> Depth 'ler Material(Below 50'1 tv <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION EPAIR/ DDITION DESTRUCTION I I (No septic system permitted if public;s~ <br /> available within 200 feet.) "r <br /> G s <br /> Installation vnll serve: Res/idenceCommercial Other _ z: <br /> Number of living units:L Number of rooms }'��y.T q may' " •" <br /> Character of soil to a depth of 3 feet: Water tab i depth�L <br /> x- <br /> SEPTIC TANK ❑ Type;Mfg Capacity No. Compa.tments <br /> PKG.TREATMENT FLT.❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line w <br /> LEACHING LINE ' No. &Length of lines , � Total length/size <br /> ►u 5 <br /> r i i <br /> FILTER BF.D ❑ Distance to nearest: Well .moo Foundation Property Line r <br /> SEEPAGE PITS I Depth Size ftumber �r _ <br /> SUMPS, L_1 Distance to nearest: Wel; Fwndat;on _ Property Line <br /> DrsPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work,will be done in­cordance with San Joaquir county ordinances,W"Uwa'Ve <br /> afld <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner u!licensed agent's signature ceWf as the following:"I certify that in the performance o1 the work for which this permR is Issued I shah Iqt " <br /> employ any person in a such manner as to become subject to workman's compensation lawn of California."Contractor's hiring or sub-contracting tignafufl"� <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's <br /> tion laws of ifornia." - --- (' <br /> The apW cant t call fon l r uir inspections.Completa d•awing on reverse 6idel - "" - "t <br /> J -M <br /> Title: I Date: <br /> Signed X ` <br /> / � <br /> _ FOR DEPARTMENT USE ONLYt <br /> Appiicetion Accepted by Datti-1y�- 2� Arsa <br /> Pit or Grout inspection by / Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 461rc781 O Lodi 369-3621 ❑ Manteca 82:'-7100 Ci Tracy 895-6385 �•` <br /> Applicant- Return all copies to: Environmental H6elth Permit/Servicsa 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,C,A 95201 hrr <br /> FEE CK <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DA'Z'E pERMITNO. <br /> INI 0 >:•..>rtai:..:. <br /> .EH 13-24 rREv. <br /> EH 1�.2a r - -.ta!•t� <br /> y c <br />