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�� a <br /> APPLICATION FOR PERMIT P44 <br /> --' SAN JOAQUIN LOCAL:"HEALTH DISTRICT � <br /> 1601 E.`k AZEL I ON AVE., STOCKTON, CA <br /> � <br /> Telephone (209) 466-6781 <br /> i PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const ct a /or install the workCreiq described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 f we pump and the Rules' nd Regulations of the San Joaquin <br /> Local Health District. �' l <br /> Job Address / �+� N�fA rW .4// City Lot Size . PM <br /> Owners Name �` �. � �� � / Z-Address �} +✓ one° 7 <br /> Cbnt ractor ne <br /> TYPE OF WELL/PUMP: NEW WELL s� WELL REPI ACEIMENT ❑x DESTRUCTION ❑ ' <br /> PUMP INSTALLATION ., SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -`�� SEWER LINES DISPOSAL FLD,'., PROP. LINE <br /> FOUNDATION '_.fes.._.__...- AGRICULTUR ELL OTHER WE7 PITS/SUMPS L <br /> INTENDED USE TYPE OF WELL l PROBLEM AREA STRUCTION.SPECIFICAT <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia;of Well Excar�ration� - %Dia. of Well Casing <br /> _a , <br /> omestic/Private ravel Pack El Tracy Ty1pe of Casing �, - Specifications <br /> LI Public El Other � � El Delta 4V E%pth of Grout Seal ��� "t—;__Type of Grout A1A)` <br /> 1 <br /> O Irrigation 110_Approx. Depth ❑ Eastern .#� Surface Seal Installed by (5Mj,&1AM0Rl <br /> Repair Work Done ElType of Pump - ---H-P: 1L ;ft-^— State-Work-Dories <br /> Well Destruction ❑ Well Diameter ` ^ Sealing Material (to`p 50'i <br /> Depth i ' r - Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,O REPAIR/ADDITION ❑ DESTRUCTION ❑ (No s@pti-c system permitted if public isewer is 1 <br /> available within 21;17 04eet:)= <br /> 1. Installation will serve. Residence_f Commefcial_ Other <br /> Number of living units: Numb of bedrooms- <br /> Character <br /> edroomsCharacter of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK iCl`s Type/Mfg Capacity -�_No. Compartmen,ts�*�� F ' <br /> PKG. TREATMENT PLT. i 1 r Method of�Dispo <br /> Distance-to Well Foundation _t_�Propert1 Line <br /> LEACHING LINE Q—No-& gthlof-lines—= .° i """(Total length/size f <br /> FILTER BED ❑ -Dista t ea rest: 611 Foundation Property-Line <br /> SEEPAGE PITS ❑ Depth .Y Sizes - I Number <br /> SUMPS ❑ ,Distance to'nearest: WeII i Foundation f ".Peperty Line I <br /> DISPOSAL PONDS l•❑.rte �� ± �_.. I .j�� r + - t <br /> i'hereby certify that I have.Otepafed-tRi"pplicatioi�-and that the work will be done in accordance with-San Joaquin county ordinances, slate laws, and I <br /> rules and regulations of the'Saoaquin Local Health`District. <br /> i <br /> Home owner or licensed;agent''s sigriaiure certifies the fallowing: "I certify that'in the-peff rma ante of the work for which this permit is issued, I shall not- - { <br /> employ any person in such.ma i%er as to become subjectlt'o wofk'man's.compeCssation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certif.githat 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."`? ' y a <br /> The applicant m r_=1r requir m pecoons. Comlplete da' ing on reverse sid SignedI `Title: /y Date: <br /> - FOR DEPARTMENT USE ONLY d . <br /> Application Accepted by �'� Date 4­�3 Area <br /> Pito Grout tion by Date L Final Inspection by �, 1 r Date <br /> ± Additional Co �,E�''t <br /> r <br /> O <br /> St <br /> k 466 6761 t L7 LodP,369 3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Y <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> EE -- -- , 1 . .CKt . - <br /> AMOUNT DUE AMOUNT FtEMlTTED �\.[ RECEIVED BY DATE PERMIT NO. <br /> INF�� x x Y CASH, <br /> ' �L _ <br /> r <br /> + EH 13-24, 11. <br /> EH <br /> EH f4.28 '—ar"'*i."'r.: • ��J + - L `� _ �.f <br />