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APPLICATION FOR PERMIT <br /> ' 'l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'A Z �f 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete III Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a perms to construct andtor install the work herein described. This application is <br /> made in comphanco with Sari Joagwn County Ordinancu No 544 for sewage or No 1RS1 for wet::pump and the Rules and Regulations or trio San Jcaquin <br /> Local Health District <br /> 1 �IO J. ((SY/it' n City .t..� Lot Site ���� PM _ <br /> Job Address �-7 _-__.. __—�_—� - -- --'-" <br /> Owner's Name Address <br /> Contractor_FZO}�y LG4soD _Address_I_��i-e-,e;�- __. License No. -���_(v _ Phone <br /> TYPE OF WELL/PUMP: NEW WELL P, VVFL 1. REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION I' SYSTEM REPAIR i OTHER 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _— PROP. LINE <br /> FOUNDATION AGRICULTURE WEII OTHER WEI L -- PITSISUMPS_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Indusireel U Open Bottom C) Manteca Dia. of Well Excavation ____ __ Dia of Well Casing <br /> C Domestic/Private D Gravel Pack ❑ Tracy Type of Casmq -_. —_ Specihcahors <br /> ( Prrhhc n Olher ("7 Delta Depth of Grout Seal ___ Type of Grout r. <br /> I Inil)arion —Approll, Depth I I Eastern Surface Seal InswIlud by _ - -- <br /> Repair Work Dore i 1 Typa of Pump —_ H P- Stale Work Done <br /> Wan Destruction I Well Diameter —_ Sealing Material (top 501 _ — <br /> Depth Filler Material l8elow,501 ___.. . <br /> TYPE OF SEPTIC WORK NEW INSTALI.ATION i I fit%'A►f1 Ar)DiTIONX DESTRUC71ON : I (Nor septic system permitted it public sewer is rry <br /> available within 200 feet.) <br /> Installation will serve- Residence r-/ Conlrnen:ial ---__ (other .-- <br /> - Number of living units -I__ Numxr of bedrooms Z- <br /> Character of soil to a depth of 3 feet __.?J V Y Water table depth <br /> SEPTIC TANK 0 Type/Mfg _________ Capacity -- <br /> No. Compartments _ <br /> PKG TRFATMENT PLT.El Method of Disposal _ _- <br /> Distance to nearest Well Foundavon Properly I one <br /> LEACHING LINE ./No. 3 Length of fine I — 70 Total lengthrsrce. 7G� _— <br /> FILTER BED I ; Distance to nearest; Wep — Q— Foundation _�D Propeny Line <br /> SEEPAGE PITS I Depth Sire Number <br /> SUMPS I I Distance to nearest Well Foundation "_.__- . Property Line <br /> DISPOSAL PONOS <br /> I hereby cartify that I have prepared this application and that ine work wu1 lie dune on accordance with San Joaquin county ordinances, state laves, and <br /> rules and regulations of the San Joaquin Local Health Distract. <br /> Home owner or licensed agent's signature Certifies the followin47: '1 certify that in live purfoimanco of Uta work for which this permit is issued, I shalt not <br /> employ any person in such manner as Ir,become subject to workman's compensation laws of California.- Contraetnr's hiring or sub contracting signature <br /> certifies the folkewing "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject Io workman's compensa <br /> tion jaws of California." <br /> The applicant must call for all roquirod inspections Con119ete drawing on reverse side. <br /> A" <br /> Signed X < e,.� "a Title !�'>'�'`. __ Date: q-) 7 <br /> OA DEPARTMENT USE ONLY <br /> Application Accepted by _ / _U _ _-_ Date _ _ Area 1 <br /> Pit or Grout inspection by — __ — Date Finer Inspection by _'_ __..- bats • ' <br /> Additional Comments' ___ _—___ ___ <br /> f -1 Sok. 466-6781 L Lodi 3693621 f: Manteca 823-7104 L Tracy 835-6385 <br /> LApplicant - Return all Capretl to: Environmental Health PermrtrServices 1601 E. Hazelton Ave.. P 0 Box 2M. Stk.. CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED �— RECEIVED BY DATE PERMIT NO <br /> INFO / ]]£ASf� j ///4 �j {�•j �J <br /> • FH 1174 rH 147e INfV 1 t•7 ` r,, �l P <br />