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.+�ritl.NlltJIV hUH PERMIT ,t. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT :. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 �Q d4Piyru <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) e4 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ak herean described i This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Re ulijt'o <br /> Local Health District. gt 1 1p,6)1 4Joaquin <br /> Job Address City � of Size . p <br /> Owner's Na Add e <br /> t{1 ss • <br /> ELT-C <br /> Contractorame �XCAddress26VI�7 -1 11 <br /> '�l 59Cv �5 ' r <br /> - License <br /> TYN lr�htirli <br /> PE OF WELL/P U EW WELL WELL REPLACE ENT O DESTRUCTION 0 - <br /> PUMP INSTALLATION O> - SYSTEM REPAIR O OTHER <br /> DISTANCE TO NEAREST: SEPTIChTANK -W6 SEWER LINES DISPOSAL FLD~�yd PROP. LINE <br /> 11 <br /> FOUNDOF WELL C <br /> F W �� AGRICULT'URE WELL OTHER WELL ZoD f PITS/SUMPS IJV <br /> INTENDED USE TYPE PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial O Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing <br /> Domestic/Private V Gravel Pack O Tracy Type of Casina Y G S I <br /> 11 Public pecifications <br /> n Quer gOelta Depth of Grout Seal ' *0 <br /> I I Irl tion civ —y—_ Type of Grout <br /> '8a tLApA oa. Depth 1 1 Eastern Surface Seal installed by�Wu1 <br /> Repair Work Done UI Type ofP���ump H.P. State Work Done_ <br /> Weft Destruction• O Well Diatheter Sealing Material(top 50') <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 7 REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permilled if public sewer is <br /> Installation wilt serve:. Rgsidencei, Commercial, Other available within 200 feel.► <br /> Number of Going units: Number of bedrooms-�— <br /> Character of soli to a depth of 3'.1. <br /> '.1. t: fn <br /> SEPTIC TANK mpa <br /> Water table depth <br /> O Type/,Mfg Capacity No.Co <br /> PKG.TREATMENT PLT.O i rtments <br /> I Method of Disposal l <br /> Distance to nearest: Well Foundation Property Line <br /> vi <br /> LEACHING LINE 0 No. &Length of lines �✓ <br /> FILTER BED 0.. DistanTotal length/size Ij <br /> ce to pearest: Well Foundation <br /> I� Property Line <br /> SEEPAGE PITS I I Depth. Size 9 <br /> Number <br /> SUMPS <br /> L7 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> rules and regulations of the San Joaq <br /> I hereby certify that 1 have � <br /> prepared This application and that the work will be done in accordance with San Joaquin county ordinancesl state laws, and <br /> uin Local Health 011trict. <br /> Homs owner or licensed agent's signature certifies the following:-I certify titer in the performance of the work for which this permit is' ed,I shalt not <br /> Y any Pelson in such manner as Ito become subject to workman's compensation laws of California."Contractors hiring or sub-connecting signature <br /> certHios the following;'7 certify that in the performance of the work for which this permit is issued,I shall employ <br /> tion Iaws of California." <br /> P Y persons subject to workman's compensa- <br /> tion <br /> applican t ca for all r ' <br /> quite d i pections. Complete drawing on reverse side. j <br /> Signed „P Q Q <br /> � � Title: 1.���l-r-r� i mow/ Date: U12i7dS/" <br /> j <br /> FnA DEPARTMENT USE ONLY <br /> .Application Accepted by ' pate O � �Q 'T"✓��-. . <br /> // n / --�� Area <br /> Pit or Grout Inspection bypCn,�e-c-s, Date �1 x1 7 0 <br /> Final Inspection by Date 2 0 <br /> 'Additional Comments: Z(St#/ aylow��•'{�Z//Cfc <br /> ❑Stk 466-6781 ❑ Lodi 369r3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Y009 Stk., CA 95201 <br /> FEE AMOUNT DUE <br /> INFO F AMOUNT REMITTEDCASH RECEIVEp BY DATE f' <br /> PERMIT'NO. <br /> 4-26 <br /> 1 •� <br />