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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> .This <br /> tion is <br /> AppGyation u lance wit,Sae the Jososan County O d,naLocal <br /> nce No.549 for sewage orpermit <br /> No. 1862 to,we 1,pump and the Rules end heroin <br /> Regu atbm of M Sa�i,uoaVuln <br /> made in eotripb <br /> Local Health D+slrKt. Di v�JGl�L �a l� ; <br /> � <br /> � ��� v1� Size_ PM <br /> Job Address LL512 _ <br /> (-_ M nY li�'� Address Phone <br /> pwr,vi s Name <br /> '3SO �.J, ` OI- License No.y-�r,sa9 Phone O I <br /> Con'.ractor !hnl L ("r~`-/---Address <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE WELL/PU1APo SYSTEM REPAIR U OTHER ❑ <br /> PUMP INSTALLATION ❑ PROP. LINE <br /> DISTANCE TO NFI.REST: SEPTIC TANK _ <br /> SEWER LINES DISPOSAL FL— PITS/SUMPS <br /> - <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL _. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing <br /> ❑IMkuhial ❑Open Bottom C; Manteca Dia.of Welt Excavzrion Dia.offWellSpecifications - - <br /> Type of Casing <br /> ❑OpncstiC/Private ❑Gravel Pack ❑Tracy Typ•of Grout_ <br /> ❑puyLK ❑Other Fl Delta Depth of Grout Seal _ . <br /> 1 I Irrigation _Apprm. Depth I I Eastern Surface Seal Installed by <br /> - <br /> H.P. <br /> State Work Done_ <br /> Repair Work Done L3 Type of Pump - <br /> won Ihnn on Cl Welt Diameter Sealing Material (top 501 <br /> Depth Filler Material(Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 nU'AIR'ADDITION STRUCTION 1 availe IN le�wditi t 20c system 0 feet.�ed it public sewer n <br /> lm as ion wal serve: R • L- Commercial Other <br /> Fluid- r of kvir,p uMs: Number of bedrooms=Z Water toble depth <br /> Charn.M of sa to a depth of 3 feet: L ('7 <br /> SEPTIC TANK CiType/Mfg Capacity] No. Compartments <br /> PKG.TREATMENT PLT.❑ P <br /> } L C O Ncr-CtE— Method of Disposal <br /> Distance to nearest: WetlFoundation_—_ Property Line <br /> /-5 <br /> kin � <br /> LEACHING LINE Com.6 Length of lines <br /> __ �_ Totagth/size_ <br /> FILTER BED ❑ Distance to nearest W,41.. Foundation--- <br /> — Property Line <br /> SEEPAGE PITS <br /> 1 I Depth __ Size Number <br /> SUMPS it Distance to mi Well __ Foundation Property Line <br /> DISPOSAL PONDS 11 <br /> I haraby mortify roar I Nva Tt`ared this applkatlon.and that the work will be done in accordance with San Joaquin euunty ordinances.nets rewire,and e <br /> rules and reguWroro or the San Joaquin Local Health D3tr¢t. <br /> Home owner or kcan"d sgmlt's signature candies the following: "I certily That in me Performance of the work for which this Permit H issued,I shell not <br /> employ any parson in such runner as to become subject to workman's compensation laws of Calilornia."Contractor's hiring or wDcontracting agMitrre <br /> Carydw the foaowing:"1 certify that in the Performance of the work for which this permit is issued.I shall employ persons subject to workman's compel <br /> iVn 1 CNaOrnia." <br /> The pppliran t uX ah r fired Petri ns. Co. i drawingVal"si <br /> �__ Title1 �rrt n J' A�? Uam - <br /> 59: <br /> / — 1 L 1\ FOR DEPARTMENT USE ONLY <br /> D <br /> `� _ ate L _� ��Arsa <br /> Application Accepted by `/� ._ ay <br /> Pit a GrM Inspection by <br /> DYm__— Final Inspection by Dete -- <br /> Additkinal Cortvnents: <br /> 7 Stli 466.8781 ❑Lodi 3693621 ❑ Manteca 823710/ ❑Tracy fl7S83B5 <br /> Lpplicant-Return all COER"10: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. Stk.,CA 95201 <br /> FEE AMOUNT REMITTED CK a RECEIVED BY DATE PERMIT NN� `\ <br /> AMOUNT DUE CASH <br /> INFO <br /> .EN9 raze iaev. •.. I fps-/ <br /> EN,ass <br />