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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f (Complete in Triplicate) <br /> _ Application is hereby made to the San Joaquin Local Health District for a permit to 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/Dump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> X00 AGG'C3 <br /> Job Address �S� �. TADD6/ .QD City Lot Size PM <br /> Owner's Name VERA/ V EP...2A Address «/P Phone <br /> Contractor i"j/o .E . Lzw.UZ Address License No. Phone <br /> b 3Q7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ t WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> J <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINES DISPOSAL FLD. PROP. LINE / <br /> FOUNDATION --• -- AGRICULTURE-WELL — -OTHER WELL PITS_ <br /> /SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARBA CONSTRUCTION SPECIFICATIONS �y <br /> 0 Industrial O Open Bottbm 0 Manteca Dia. of Well ExcavationDia. of Well Lasing <br /> ❑ Domestic/Private ❑ Gravel-PacKi - 0 Tracy \Type of Casing 1 .I .r `• ' Specifications <br /> f'1 Public ,fEl Other 1_ t. FI Delta Depth of Grout Seal '�'°/ Type o?Grout_. <br /> I I litigation i_ApprW Depth _ I I Eastern, Surface Seal.lnstatled_ by _ <br /> Repair Work Done 0 Type of Pump •' H.P., r `� '� State-Woonerk-B _ - <br /> �1 <br /> Well Destruction El Well Diameter ' �� ` Sealing Material- op 501 <br /> Depth{ t— Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW;INSTALLAT4available <br /> REPAIR/ADDITION DESTRUCTION I I septic system permitted if public sewer is <br /> / available within 200 feet.) i <br /> Installation will serve: Residence Commercial_ lother' <br /> Number of living units: -A-1 Number of bedrooms-3 ";t <br /> Character of soil•to.a,depth of 3 feet: Watectable depth <br /> SEPTIC TANK ❑s Type r O/Mfg - {y(Ts-T9i�- Capacity 1No. Compartments <br /> PKG. TREATMENT PLT.0 .0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE No. 8 Length of lines / BOO / Total length/size /DO'X •i <br /> FILTER BED Q/Distance to nearest: - Well 1r40' Foundation �z Property line 71 z <br /> SEEPAGE PITS WID.pth J'S' sizeY - 'Number <br /> SUMPS Ll Distance to nearest: Well E z Foundation 7� Property Ling 7S <br /> DISPOSAL PONDS 0 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 5 rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:."1_certify that in-the-performance.ofthe work for which this-permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <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 compensa- <br /> tion laws of California." �-- �/ .-. r .- <br /> Tile <br /> -The applicant must call for all required inspections. Complete drawiWgl on reverse side <br /> 4 <br /> Signed X S= 1�+-+d/ LIiS*•a'2f/ "Title: aft;& Date: •�•�'8� <br /> FO USE ONLY <br /> i}r Application Accepted by �n :�:��/i= A. �4• +Mli•^-� Date Area (2 <br /> "R Ph or Grout Inspection by Date Final Inspection by Date �- - <br /> Additional Comments: <br /> 0 Stk 486-6781 0 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 _ <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 s <br /> w <br /> _ w a <br /> INFO MOUNT DUE AMOUNT REMITTED I CCA H RECEIVED BY DATE PERMIT NO. <br /> . EH 1a-24IREV,t/em �n -A/1 ti+i+� <br />