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RM
<br /> APPLICATION AOR PE IT •.
<br /> } ' SAN JOAaU'IN LOCAL'' HEALTH:`DISTRICT.' <1
<br /> 1601. �E,,HAZEL rON:AVE:;.STOCKTON; CA r'• }
<br /> ' ,Telephone ('") 466-678T :,
<br /> PERMIT.EXPIRMS i YEAR FROM 'DATEAS$UED ` . ,
<br /> (Cbrnplete in-Triplicate)
<br /> Application is hereby made to the San Joaquin Local.Health District for a,permit to construct and/.or iristall the vvark herein described.,This application is
<br /> made in compliance with.San s
<br /> Joaquin County Ordinance No.549 for ewage.or No.1862'for well/pump"and tFie Rules and Regulations of the San Joaquin
<br /> 71
<br /> .. Local Health District
<br /> Job,Address + C�7 ` R,v + l1Ul +1J City 1 dtd ' Lot Stze r s E+'. fM
<br /> Owners Name 1� t W� � (Address �[��� S �y��N�1�.4� n+ Phane:
<br /> *,
<br /> Gdressongactor l 1101 RI1� Ad „ �3e ���0 :
<br /> License No. Phone I
<br /> TYPE OF WELL%PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑
<br /> PUMP INSTALLATIO_ N ❑ . , SYSTEM REPAIR ❑ OTHER ❑ t
<br /> DISTANCE.TO NEAREST: SEPTIC TANK .SEWER'LINES DISPOSAL-FLD. PROP.:LINE
<br /> FOUNDATION ' AGRICULTURE WE=LL OTHER WELL PlT$/,SUMPS
<br /> INTENDED USE TYPE OF WELL-.'-..,*,'
<br /> ELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS, .,
<br /> L Industrial. ❑ Open goftom ` ❑ Manteca ,Dia.-of Wal Excavation Dia of W611:Casing, i
<br /> ❑ Domestic/.Pnvate '� O Gravel Pack 0.Tracy y ,Ty'pq,gf Casing Specifications A
<br /> ` ❑ Public -0 bthdr. - Delta Depth of Graut Seal Type of Grout
<br /> L
<br /> © Irrigation ---Approx. Depth: ,❑ Eastern ,"Surface Seal installed,by
<br /> Repair Work Dane ❑ Type of,Pump H.P. State Work bone t
<br /> Well Destruction -Q'• --.Well Diameter :Sealing Material flop 501p t
<br /> - Depth' rFdler Material (Below 50)
<br /> TYPE'OF SEPTIC;WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION (No"se¢t1c sysiem permitfed'if;putiiic sewer is
<br /> available within 200 feet.), ,
<br /> .Installation will serve:- Residence Commercial: Other +'
<br /> Number ofaiving units:' r. Number of edroams
<br /> Character of,`soil to a depth of•3 feet: Z1V V41a'ter table depth
<br /> SEPTI.C"TANK 0 TypelMfg Capacity :/ -06 No>Compartnients 1
<br /> PKG. TREATMENT-PLT. ❑ Method gf.Disposa! 3 f
<br /> Distance to nearest: ',WeII Foundation Property.Line� x
<br /> { '
<br /> LEACHING LINE (3�No. 8 Length of lines' 7 Q.. ! ,;
<br /> 9 � � �,,.. '' ��7�`��,,-T��ota f lengthlsize
<br /> " FILTER BED., fl Distance to nearest: WeII�_ Foundation_�_6 ..Property Line [D{QVQ
<br /> SEEPAGE PITS ElDepth Size 'Number
<br /> SUMPS ❑: "Distance to nearest " -Well:_-_._40 Foundation Property.,d
<br /> ;DISPOSAL PONDS ❑
<br /> hereby certify that I have prepared-this•application and that the.work''wlll be done in accordance with San Joaquin county ordinances,.state'laws,'and
<br /> rules and regulations'of t_he`San Joaquin Local Health District.
<br /> Ho"me"owner or licensed a ant's si naturae certifies ihe.folloviiin I -
<br /> g g g: "I certify that in the performance of the work'for which this-permit is issued, I shall not
<br /> 'employ any person in such manderas-to liecorhe subject to-workman's compensation laws'of California."Contractoi's hiring or sub-contracting signature +
<br /> certifies the following:"I c6rtify'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." , `"� 'i ,
<br /> t r.: t: `sem°. "';-�s. , a<,:r. ,..Y. ; -•..,•r � .
<br /> The applicant must call,for all r'equired:in ctions Cam" Tete drawing on reverse side .,• �M'. i
<br /> Signed Title `. r :s�AJ@tom , Date:
<br /> f , FOR:DEPARTIMENT USE ONLY ,
<br /> < . r
<br /> Application Accepted by f` date Area t
<br /> Pit or,`Grout Inspection- �Daie .t Final lirspection4iy v 'Date .
<br /> A itional Comments: .
<br /> Stk 466-6781. ❑ Lodi,: 369-3621• ❑ Manteca '823-7104 fl-Tracy 835-6M;f 1
<br /> licant- Return all copies to: Environrtieiibl Health Permit/Services 1601 E, Hazelton Ave P O. Box 2009,.Stk., CA_ 95201
<br /> FEE—.. -.._._ _ Y ..� •- ._. . . -- CK _ LL_
<br /> INFO AMOUNT DUE AMOUNT REMITTED RECHVEDtBY, DATE PERMI7'NO.
<br /> ' [
<br /> -. s'EH1&241REV.ve57 .�O �
<br /> EH 1428t2-13
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