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APPLICATION FOR PERMIT <br />A <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />Yi 1601 E. HAZE TON AVE., STOCKTON, CA <br />Telepho ie (209) 466-6781 <br />PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Appl"foil is twebv 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 Ordinaries No. 648 for sewage or No. 1862 for weilipump and the Rules and Regulations of the San Joaquin <br />Local Health District. <br />Job Address V -3 " '-" " + _' 1 City �— lit Size <br />Oww l,,. Addrase J i �J ' Phone <br />C�ltractor Address. License No. - Pherla <br />PAA <br />installation will serve: Residence _ _ Commercial _ Other <br />Number of'frvlrlg units: Number of .fes <br />Character of soil to a depth of 3 feet: J 1 Water table depth <br />SEPTIC TANK Ci Type/Mfg Capacity L No. Ctartp»rtmerrts <br />PKG. TREATMENT PLT. C1Method of Disposal Aevow <br />Distance to nearest: Well ZIP �Foundation Property Line ' <br />LEACHING UNE p No, b Length of lines • <br />FILTER BED Cl Distance to nearest; V44 <br />fiat31i <br />Property Line <br />EEPAGE P—ft 1 Depth --Sue Slate r Murr" <br />0 Distance to nearest: W4118 Four>d n ------.- Property Lida <br />rgtcortcz,r 0111 rlc Cl <br />f hereby certify that I have preparid this application arid that the work "tel be dorle`in darica with San Joaquin county ordinances, etAte hWA, and <br />neles and regulations ofthe San Joaquin Local Health Os�trict. � <br />Houle owner or licensed agent's 4nature certifies the following: "I ce *y that in, the pe of true work for V"r h this permit is tastued, I "I not <br />ampkay any person in such nsa< VW as to becorna Subject to workman's 00Mpeasajion taws# of Califon ia,-Cwtractoes tiring or sorb -contracting signature <br />canifies the following: "I carW that in the performance of the work for v,�sich this 4e#mit is iSsued. I shall employ persons subject to , �P k n's compensa- <br />tion laws of Cd ifornia: _ _.. <br />The u call for a rfpuued in . Compista drawing on reverse side. <br />"1 <br />Sign Title: " �"%- - --. —. <br />FO � USE`ONLY <br />13 <br />Application Accepted by �l Q:y Arca <br />Fit or Grout Inspection by Date Final Inspacfm b1+ Dale — «--- <br />Additional Comments - <br />0 Stk 486-5781 0 Lark 369.3621 Cl Manteca 823-71114 0 Tracy 113 <br />Applicant - Return all copies to: Environmarttal Health PennitlServic" 1601 E. Hazelton Ave., P.O. Box 2WS, Stk., CA SSM <br />FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT' W. <br />INFO <br />.. � las+ <br />EH 14]19 <br />PUMP INSTALLATION D SYSTEM REPAIR 0 OTHER O <br />bISTANCE TO NEAREST: <br />SEPTIC TANK <br />SEWER LINES, DISPOSAL FLO. <br />PROP. UNE <br />FOUNDATION <br />- - AGRICULTURE WELL OTHER WELL <br />PITSMMIPS _. <br />INTENDED USE <br />TYPE OF WELL <br />PROB AREA CONSTRUCTION SPECIFICATIONS <br />7 Industrial <br />0 Open Btmom <br />CI Manteca Dia. of WsM Excavation <br />Dia. of Well Casing <br />rl Dorllestici Private <br />C`I Gravel Pack <br />?o Tracy Type of Casing <br />Specifications <br />(I public <br />n other <br />M Delta Depth of Grout Seat <br />Type of Grout <br />I i irrigation <br />,,,,._..Approx. Depth <br />1 1 Eastern Surface Saes insaalled by <br />Repair Work Done L3 <br />Type of,Pump <br />H.P: $lltte Wak 04" <br />t <br />9 � <br />Wen Destruction © <br />Wen Diameter <br />Sealing Material Itop 50') <br />tit <br />Filler Materiel (Below 501 <br />TYPE OF SEPTIC WORK; <br />W MTALL.ATiON 1;1 REPAIR160DITION I i DES " JCTION i J (No septic systarn permitted if public is <br />avaAabIq,,Wthtn 200 feet.) <br />installation will serve: Residence _ _ Commercial _ Other <br />Number of'frvlrlg units: Number of .fes <br />Character of soil to a depth of 3 feet: J 1 Water table depth <br />SEPTIC TANK Ci Type/Mfg Capacity L No. Ctartp»rtmerrts <br />PKG. TREATMENT PLT. C1Method of Disposal Aevow <br />Distance to nearest: Well ZIP �Foundation Property Line ' <br />LEACHING UNE p No, b Length of lines • <br />FILTER BED Cl Distance to nearest; V44 <br />fiat31i <br />Property Line <br />EEPAGE P—ft 1 Depth --Sue Slate r Murr" <br />0 Distance to nearest: W4118 Four>d n ------.- Property Lida <br />rgtcortcz,r 0111 rlc Cl <br />f hereby certify that I have preparid this application arid that the work "tel be dorle`in darica with San Joaquin county ordinances, etAte hWA, and <br />neles and regulations ofthe San Joaquin Local Health Os�trict. � <br />Houle owner or licensed agent's 4nature certifies the following: "I ce *y that in, the pe of true work for V"r h this permit is tastued, I "I not <br />ampkay any person in such nsa< VW as to becorna Subject to workman's 00Mpeasajion taws# of Califon ia,-Cwtractoes tiring or sorb -contracting signature <br />canifies the following: "I carW that in the performance of the work for v,�sich this 4e#mit is iSsued. I shall employ persons subject to , �P k n's compensa- <br />tion laws of Cd ifornia: _ _.. <br />The u call for a rfpuued in . Compista drawing on reverse side. <br />"1 <br />Sign Title: " �"%- - --. —. <br />FO � USE`ONLY <br />13 <br />Application Accepted by �l Q:y Arca <br />Fit or Grout Inspection by Date Final Inspacfm b1+ Dale — «--- <br />Additional Comments - <br />0 Stk 486-5781 0 Lark 369.3621 Cl Manteca 823-71114 0 Tracy 113 <br />Applicant - Return all copies to: Environmarttal Health PennitlServic" 1601 E. Hazelton Ave., P.O. Box 2WS, Stk., CA SSM <br />FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT' W. <br />INFO <br />.. � las+ <br />EH 14]19 <br />