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{� Ai'F'LICATIONRM <br /> . <br /> SPA PERMIT <br /> SAN JOAQUIN Lt�CAI� HEALTH DISTRICT <br /> 1601 E. HA2ELfiON AVC,'StOCKTON, CA <br /> Telepl~�iy� 12b9) 4tE-S7�i ; <br /> PERMIT EXPIRES'I�Yr AIi "OROM bATE ISSUED . ' <br /> ICompl�te i11.r�`riplic6tel. ; <br /> Application is hereby made to the San Joaquin Local Health District fdr a permit to construct and/or Install the work herain described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewag®ttt No,862 for Well/pump,and the,Flutes and Regulations of the Sari Joaquin <br /> Local Health District. <br /> ,rob Address ;City, Lot Size PM <br /> Owner's Name <br /> ' Address 's r' Phone <br /> Contractor�� 1 Address (0 1 t No.Q27 10_, Phone 15 <br /> TYPE OF WELLMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Ill SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.:: PROP. LINE <br /> FouNDATIoN AGRtirULtUi1i} 11t 6TIiER WELL PITS/SUMPS <br /> INTENDED USE TYPE OP WELL. PR08LEM AREA CONOI LI&ION SPECItICATIONS <br /> C7 industrial CI Open Bottom ❑ Manteca bia 'o W611 Excavation: bis. of Well Casing <br /> I I Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing <br /> Specifications <br /> I') Public n Other n Delta Depth of Grout Seal Type of Grout <br /> )4 Irrigation --Approx. Depth ' 1 I Eastern Surface Sean Installed by <br /> Repair Work Done ❑ Type of Pump H.P. _ State Work bone Ar -2rdmj_ <br /> Well Destruction O Well Diameter Sealing Matel'W"lfop 501 <br /> Depth Pillar Material(helm 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 1.,DESTRUCTION I 1 (No septic system permitted if public sewer is _ <br /> available(within 200 feat.) <br /> Installation will serve; Residence Commercial Other <br /> Number of living units: Number of bedrooms 3 z <br /> Character of soil to a depth of 3 feet, I ._. � Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well 1oundatlon';,, Propdtiy Line <br /> LEACHING LINE ❑. No. r1, Length of lines total lehgth/sIze <br /> FILTER BED ❑ Distance to nearest: Well 'Ooohdatloit Ptdparty Line , <br /> SEEPAGE PITS I I Depth, Size Numb6r <br /> SUMPS L"1 Dtatance to-neateam__._;W61)_. F6jndailon Pt6oarty Line <br /> DISPOSAL PONDS ❑. <br /> I hereby certify that I have prepared this application and that the work wilt bit ddtte In accordance With Sail Joaquin county ordinances,state lades, and <br /> rules and regulations of the San Joaquin Ldcai Heaith 154trict. <br /> Home owner or licensed agent's signature oartiflda the following: `'1 certify that,Ih the perfdrmaflce bf the work for which thia permit is issued, I shall not <br /> employ any person In such manner as to becom i eubjebt;tb workman's corrij rlaetloh Iawe bf CM06thia."Contractors hiting or sub-conttacting signature <br /> certifies the following:`'I cArtify that kt the psrfbt fi h6d of the work fof Whiafl his penult is Issued,I Ithail$Moldy piteous aUblkt to workM66's compensa- <br /> tion laws of California.'` <br /> The applicant must c tier all requiredYinspoctlons. Complete draWing on rroirarsa side, {' <br /> Signed X Title rs .►" bate: '•;?�i--'3+', — <br /> EobI' A1'MN1`use C1NLY ; <br /> Applicati>!rt Acceptad by Oita 4 0- r*ql Atoe `r">1Ak <br /> — <br /> Pit or Grout Inspectidh by Date_.�__�.__,�_�lttai impaction by Data J� <br /> Additional Comments:. <br /> ❑ Stk 468-6781 ❑ Lodi 369 3821 ❑ Manteca 923-7iO4 t d Tracy 836-6395 <br /> Applicant- Return all copies to., 9nvitortmahtal Health Portrilt/5arvicaa 1961 C Haialtoii Ava., P.O.'Sox 2W9j Stk., CA ti52t11 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVEb by DATE PERMI7'No. <br /> INFO CASH <br /> � EH1321(REV.1/x 5) <br /> EH 11-2e <br />