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. sit 11.34 tttlrN. t r � ts� <br />04 14.15 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />SAN JOAQUIN COUNTY <br />DATE PLUV'YNO..J <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />. <br />P O BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRES T YEAR FROM DATE. ISSUED � 3 L/ ,;z <br />(Complete in Triplicate) Y4 -~ ! <br />Application is heteby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is <br />made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. I&M for weglpump and the Rules and Regulations of the San Joaquin <br />Local Health District. <br />Job Address c`� --A^ City A LOS .riiZB PM <br />Owner's Name Address ttu X Phone <br />Conttactor'La.OXA Address License No. Phone <br />TYPE OF WELUPUMP: NEW WELL 0 WELL REPLACEMENT d DESTRUCTION <br />PUMP INSTALLATION O SYSTEM REPAIR Ct OTHER O <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS . <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />0 industrial © Open Bottorn Ci Manteca Dia. of Wag Excavation o Dia. of Well Casing <br />0 DomesticlPrivate 0 Gravel Pack © Tracy Type of Casing,. Specifications <br />l'i Public n Othuer n Delta Depth of Grant Seat Type of Grout <br />I I irrigation --,Approx. Depth I 1 Eastern Surface Seal installed by <br />VQ1 <br />Repair Work Done Q Type of Pump H.P. I State Work Doom _ <br />v <br />Well Destruction G Well Diameter Seating Material (top SU') <br />Depth Filler Material (Below 50'1 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION71 REPAIRIADDITION I I DESTRUCTION I 1 INo i;;i; � permitted If public sewer rs <br />available vAllh n 200 ieet.l <br />Installation will serve: Residence X Commercial .,_,. Other <br />Number of living units: Z 9timber of bedrooms <br />5" <br />Character of soil to a depth of 3 feet: , Water table depth <br />r <br />SEPTIC TANK let' TyWMfg f�'� !-- p j �+ ��% No. Compartments <br />PKG. TREATMENT PLT. 0 Method of Disposal <br />Distance to nearest: Well M Foundation ,__ �'..✓ Property Lire Gd 47: <br />LEACHING LINE - , No. 8t Length of ti,nes — d 1(4 ora ' 1size <br />FILTER BED Distance to nearest. Wall Iii Foundation Z12 Property Line <br />SEEPAGE PITS i I Depth %15 Size 'yXlrr X)L7 � ��..-� <br />SUMPS K"' Distance w nearest: Wav 1�_' Foundation 2 ftWW Liles �. <br />DISPOSAL PONDS L) <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 Diktrict. <br />Homo owner or licensed agent's signature taurines the following: "I certify that in the performance of the work for which this partnit 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.,. <br />The applicant must call foran required inspections. Complete drawing on reverse gide. <br />Signed X� � s5 Title: (}�1 "y�,$,� Date: 1 <br />Y <br />FOR DEPARTMENT USE ONLY <br />� I <br />Application Accepted byDaie Area <br />6r or Grout Inspection by D Fsnal Inspection by Daie <br />Additional Comments: <br />L <br />;r? Stk 466 -Ml 0 Lodi 319-3621 0 Manteca 823-7104 0 Tracy 895-6385 <br />Applicant - Return 811 Copies to: Environmental Health Pearntit/Services 1501 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 9MI <br />' <br />. sit 11.34 tttlrN. t r � ts� <br />04 14.15 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />D RECEIVED SY <br />DATE PLUV'YNO..J <br />