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APPLICATION,FOR, PERMIT
<br /> SAN JOAQUINLOCAL;H,EALTH DISTRICT
<br /> 1601 E,�HAZELTON,AVE., STO.CKTON, CA
<br /> 'Telephon'e (209)_46f-6'781" J [{ 4 q �y n }�w t y y
<br /> - 'S :', V'1901 S0 l'r acvkl"r d4.•
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
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<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or'install the work herein dekr1h;d: TNs''application is
<br /> ,made,-n'coinpliance.wiiC9h,-Smoai n(:�J;o?{aaq�u'i�n;-:C)o�unr t+yr�Oir1d.�•i-na2n'ceNo 549�forsewage
<br /> No 1862for ell/
<br /> pp,a.n4ue;RrufesandrRH6e?gI�uila f;ui�n3s of�the eLocal e ' iSia`n�J.loi�a
<br /> quin
<br /> :f l?� ,n ist �� �C�€Y �� ,
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<br /> Job Address 4”, q
<br /> ass Q �. .• .` z= t T r, 3 x nAsiz wdi u�. 'It3t�O to C '._;a 0. .<'•
<br /> sCity LottSrze PM
<br /> _ Owner's Name -1-Z 5 i7 �� Address -- :t 11� � �' Phone f
<br /> Contracts?s Name y i(/ E
<br /> - ense i 7.No. �-
<br /> is � '���� � _ Phone 46
<br /> F i (TYPE OFMELL/PUMP:; NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ t
<br /> -f PUMP INSTALLATION
<br /> aOISTANCE,TO•NEAREST -SEPTIC-TANKC ; -4 SYSTEM REPAIR
<br /> =i - SI=VIIER LINE -�i DISPOSAL FLD. OTHER ❑
<br /> =" SPO. PROP 'LINE
<br /> FOUNDATION i AGRICULTURE WELL OTHER WELLPITS/SUMPS
<br /> _ ._.r._ . .- ..._
<br /> ` KJCTION SPECfFICATIONS
<br /> •- s❑ Industrial
<br /> INTENbED USE TYPE�OF WELL PROBLEM AREA CONSTR
<br /> r L] Open-Bottom- ❑ Manteca Dia of Well Excavation ;Dia'of-Well Casing-
<br /> Tracy of C
<br /> i + alta De th of as'
<br /> ❑ Public' €c/Private ❑Gravel Pac ❑ T m9 Specifications
<br /> P Gr.. .- t
<br /> i
<br /> ❑ Other � :p-p � - -- .�,.. . _. . ,.. ,�.
<br /> out Seal Type of Groui
<br /> ❑ Irrigation Installed by
<br /> - �Approx:•Depth ❑-Eastern 'Surface-Seal
<br /> 4 Repair Work bone ; ❑ Type ot;Pump 16 H P _ I ate Work•Done �.'
<br /> Well Destruction ❑ Well Diameter �' -
<br /> 2 op
<br /> 'Sealing Material (t 50') St �!
<br /> L -.y _..___.. Depth-!- _ :- _ `Filler Material (Below 50'1
<br /> STYPE OF SEPTIC WORK: NEW INSTALLATION ❑ :REPAIR/ADDITION ❑ -DESTRUCTION ❑ (No septic system permitted if public sewer is
<br /> available within'200'feet.)
<br /> I Installation will serve: i Residence Commercial! Other ~
<br /> Number of living units: Number of bedrooms
<br /> I
<br /> }
<br /> " a.--Character of sail to a depth of 3•feet: - _ . _ ,
<br /> € - Water table depth
<br /> SEPTIC TANKCa aci
<br /> ❑ :Type/Mfg p ty No: Compartments'
<br /> Y PKG. TREATMENT,,PLT.Q K i
<br /> Method of Disposal} ]
<br /> a 'Distance to nearest:' " Well a Foundation Property Line
<br /> LEACHING LINE ; ❑ 1 No. & Length of lines Total length/size
<br /> FILTER BED [D '!Distance-to nearest. ;Well Foundation'' L Property Line 7
<br /> SEEPAGE PITS ❑
<br /> r" —`DISPOSAL ❑ Depth !Size: s Number
<br /> -r�-r
<br /> SUMPS N 12 Distancetonearest: _WeFoundation
<br /> ! I 'P
<br /> roperty Line i
<br /> ;m
<br /> PONDS . 0
<br /> - .
<br /> !
<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, andspj
<br /> rules and regulations of the San Joaquin-Local Health District. .•a• Y
<br /> i l Home owner or licensed agent's signature certifies the followin T _
<br /> g: 'Ice riffy that in the performance of the work for which this permit is issued, I shall not
<br /> employ arty-person in-such manner-as-to become subject to workman'scertcompensation laws of California."Contractors hiring or-sub-.contracting signature ,
<br /> Theapplicant!he following:"I.certify i which this'permit is issued,I shall employ!persons subject to orkman's compensa
<br /> rtify that in the
<br /> >t€on laws',of Califomia." performance of the work fork
<br /> pp cant m II for I aqui inspe ons. mplete drawing on reverse sid` i r
<br /> SignedTitle -
<br /> Date-
<br /> _ R —
<br /> FO PARTMENT,USE ONLY ;
<br /> Application Acce ted b
<br /> ,i P t Date Area—
<br /> Pit Or Grout Inspec#ion Y � i T ate w Final Inspection by�' } Data� �.
<br /> Additional Commen€ts:
<br /> 46B67l i0i -Mate -8 -7104I 36'2 ❑tTran' 835 68
<br /> Applicant Return all
<br /> t
<br /> copies to: EnvirohmsMal Health perrttit/Services 1601 E. Hazelton Ave., P.O. Boz.2009, Stk.; CA 95201
<br /> t. __
<br /> FEE 'AMOUNT DUE AMOUNT REMITTED
<br /> CK •RECEIVED BY
<br /> i
<br /> INFO. i CASH QATE, -PERMIT`NO.
<br /> +EH 13-24(REY.10/83) �c �" "t""-"• �j{^----'•r* -r••�-'••�•-. �•
<br /> r EH 14-28_. -._ E r,-_. - _- _•.,.i0^J__. - -_.-- f , --'° ....,�.__v, �i � gb-y ' -
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