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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 /> FERMI f EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t mid/or install the Nofk herein dtiscribed.7t" <br /> rs <br />..Vdv''n eci rs bribe with <br /> a n 0S So"CJ Ordinance No.549 for Sewage or No.1862 foracal Health District for a permit to cwe"/pump and the Rules and Regulations of the Sant Joaquin <br /> n:.Ae m complianca tivhfm San Joaquin <br />.,ural Health District.v /11 G f) <br /> lob Addrea __� 78-5�� /1' Glk{ D l <br /> — City 3�: CSC LII <br /> l _ _ Lot Sin <br /> Address 7 2^6 ' l �f� 2 C� Pfp <br /> lwrw's Name --- — -� - ----- <br /> Cogtlactor&,llu�s 1e��izt/�� Addres'pt.-z�r.rlu—L c Z_LicenseNo.3-9------- <br /> vPE OF YVELL/PUMP: NEW WELL P- WELL REPLACEMENT Cl DESTRUCTION C1 <br /> O <br /> PUMP INSTALLATION i7 SYSTEM REPAIR THER l7 <br /> O r <br /> DISPOSAL FLDPROP. LINE <br />-DISTANCE TO NEAREST: SEPTIC TANK __---- SEWER LINES . <br /> _ PITSISUMPS <br /> FOUNDATION__ AGRICULTURE WELL ___ OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLFM AREA CONSTRUCTION_SPECIFICATIONS <br /> Industrial C Open Bottom Manteca Dia.of Well Excavation_-_.— — -Dia.of WON Casing _ <br /> 1 Tracy Type of Casing Specifications <br /> pprtiestic/Private I Gravel Pack T o1 Grout <br /> Public (l O 11 Delta Depth of Grout Seal Type — <br /> Irrigation —J+pprox. Depth U Eastern Surface Seal Installed by <br /> Repair Work Done (1 Type of Pump H.P. State Work Done—. <br /> Well Destruction [I Well Domeier _ Sealing Material flop ST) <br /> DOPth Filler Material I8e10w 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (] REPAIR/ADDITION I.I DESTRUCTION L I INo septic system permitted if public sewer;4 <br /> available within 200 feet.) <br /> Installation wid starve: Residence-1-11Commercial_. Other / <br /> Dumber of W*V cactus: t✓ Number of 1� <br /> Water table depth <br /> Character of Soil to a depth of 3 feet:_ <br /> SEPTIC TANK F°' Type/Mfg Cowity� No.Coniparhrients <br /> PKG. TREATMENT PLT.C1 / r Method of D" — <br /> Distance to no~: WON Foundation Zf Property Line5— <br /> LEACHING LINE rr-No. a Length of lines -� — Total length/sln� — —! <br /> FILTFR BED (1 Distance to nearest: WON Foundation�— Property Line <br /> SEEPAGE PITS 41-�'DOpth Size- y.� Number <br /> SUMPS (1 Distance to nearest: WeN1jQn, Foundation 10— Property Lim S <br /> DISPOSAL PONDS L1 <br /> 1 hereby certify that I haprepared this application and that the work will be done in accords <br /> nee with San Joaquin county ordinances,stats laws.and <br /> ve <br /> rules and regulations of the Sen Joaquin Local H6e th District. <br /> that in the pe <br /> Home owner or licvmed SOWd's signature catifiea the following: "1 certtN r}omisncs of the work for which this permit it issued.1 shah not <br /> employ any parson In such mariner as to beco ns subject to workman's compensation laws of Califomia."Contractor's hiring or subcontracting Signature <br /> certifies the following:-1 certify that in time psrf"Tn&nce of the work for wh;ch this permit is issued.I shall s P"persons Subject to workman's compensa- <br /> tion laws of California." <br /> The spdics st call for.Ta'�1w-r`w7rr]ed inspections.Complete drawing on reverse si <br /> signed X Title: t Date: <br /> FOR DEPARTMENT USE ONLY <br /> are Arm <br /> Appl,cation Accepted by — C 1i <br /> �1 r � '.�-t. Date <br /> Pit tv Grout Inspection by Q .A V, Dated Ficial Inspection by <br /> Additional Comments: —lam' <br /> Stk 406.6781 ❑ Lodi 383621 CJ anteca 7101 O Tracy fSls63B6 <br /> Appacsnt• Return all copies to: Envirorin+antsl Health Permit/Services 1001 E.Hanitai Ave.. P.O. Box 2009.Stk..CA 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTTO K a iiiCE1VE0 qV DATE PERMIT NO. <br /> INFO CASH <br /> >. .tv -� <br />