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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Talephohe (209) 466-6781 <br />PERMIT` "EXPIRES I YEAR FROM DATE ISSUED <br />fCornplete in Triplicate', <br />Application is hereby made to the San Joaquin I" 14901th District for a permit to construct and/or install the work herain described, This application is <br />made in compliprica w;tf-, San Joaqigin County Ordinance No, 549 for sewage at No, 18&2 for wellipump, and %no Rules and Regulations of the San Joaquin <br />Local Healit' District. <br />Job Address f^City Lbt Size PM <br />Phone <br />Owner*s Nameel Andress <br />Ctyntract -194 Jalh (o Andress L-ul <br />�gZ7 <br />License <br />TYPE OF WELL/PUMP .1 NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION n <br />PUMP INSTALLATION 0., g, SYSTEM REPAIR 11; OTHER 0 <br />DISTANCE TO NEAREST . SE I PTIC TANK DISPOSAL PROP. LINE <br />FOUNDATION AGRICULTURE` ELL OTHER WELL PITSISUMPS <br />.......... <br />iNTE-NDFO USE TYPE OF WELL PROBLEM AREA 'CONSTALICTiON SPECIFICATIONS <br />Dia. of Well Casing <br />lnoustriai r'] Open, Bottom U Manteca Dia. of Wall Excavations <br />:71 Gravel Pack Tracy Type of Casing-Specifications1 <br />f'! Public [1l other Fl Delta Depit-, of Groot Seal Type of Grout <br />1 1 irrigation —Approx, Oepvh I I Eastern Surfacer Sea; installed by <br />Repair Work Done LType at Purnp, State Work Done <br />Well Destruction C We" Diameter Seating Material trop 601 — - ----- . ..... ... <br />Depth at iselow <br />TYPE Of SEPTIC WORK: NEW INSTALLATION i: EPAIORII�AnOVIIOiN,A' DESTRUCTION INN septic system Pet"titted if 0-h1w. sewer is <br />available within 200 iw,) <br />Installation will serve: Residence Other <br />Number of living units: —/-- Number of bei$oorns <br />Character of soil to a depth of 3 feet, —N� water table depth .. . . ..... .............................. <br />SEPTIC TANK X Type/Mfg 1!elit Capllcitli:j No. Compartments <br />PKG. TREATMENT PLT, r- Method of Dnosal <br />Distance to nearest: Well ,JJ) Foeritiation <br />Property Line <br />........ . ... . ......... <br />LEACHING LINE Xlf No, A Length of lines ............ /." "A/p_. Total length/size <br />FILTER BED 0 Distance to nearest: Well t roindation <br />Property Line <br />9 <br />SEEPAGE PITS Depth Sixa 3-23--- Number <br />Disiance to nearm: Wi�j <br />SUMPS FoundilicJ Property Line .e. <br />I <br />DISPOSAL. PONDS 11 <br />I 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 />rules and regulations of the San Joaquin Local Health 04ffict, <br />Horne owner or licensed agent's signature certifies the following- "I certify that in the performance of the viork for which this perivil is issued, i shall not <br />arriplo-to any person in such mannan as to became subject to w0fkmari,s crrmpen5ationt jaws of California." Contractoes hiring Or suit-convactino signature <br />certifies the following: 1 certify that in the performartca of the wwk for which this permit is issued, I stWi employ Persons subject to w0tknian*s ec`mPansa' <br />tion laws of California," <br />The applicant Mu 0 for all r�C—,)L <br />4Iona. Cohiplete drawing an reverse 'do <br />7"TitleSigned X---7 77. P <br />0 FOR VE'PARTMENT USE ONLY <br />IY� <br />'Application by <br />Accepted Date Area <br />at Grout Inspection by Inspection by <br />Additional Comments: <br />0 Sjk 4WMi 0 Lodi 365-3621 C1 Manteca 823-7104 CI Tracy 835-fi386 <br />Applicant - Return all copies to: Environmental Health PermitlSsivicas 1601 E. Hazelton Ave., P.O, Sox 2MG, Stk., CA 56201 <br />-EH 13-241REV. <br />CH 14,2e <br />lVFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />4 <br />cx CASii <br />ficftvio by DATE PEA M IT NO. <br />A <br />