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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> / 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> L ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ndlor install the-work herein described. 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 Regulations Of the San Joaquin <br /> Local Health Oi�strriicL C7 <br /> d4 7,00 SA 4,17,11 RA-- City � Lot Size � '�•a�i PM <br /> Job Address <br /> � / R�LPF. Addreo 26/ ./�' Phone — a <br /> Owrreis Name Y <br /> Contractor <br /> Address 1` License No. BOAC <br /> TYPE OF WELL/PUMP:. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSALLATION 0 <br /> SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION <br /> AGRICULTUtIE.WELL OTHER WELL PRS/SUMPS _ <br /> INTENDED USE TYPE OF.WTiLL PROBLEM AREA CONSTRUCTION SPEC04CATIONS Oe of Wall <br /> CeaeB <br /> 0 mdutttrial 0 Ogen Bottom O Manteca Dia. of WWI Excavation BPKKkatiorfs <br /> Tracy Type of Casing <br /> 0 DvmesticiPrivate 0 Gravel Pack ❑0DWta Depth of Grout-Seal --Type W Grout <br /> I'l Public (-I Other - <br /> Approx. Depth t 1 Eastern SuriacaSeal InstWMd W - - <br /> 1 Ipigation -H P.' `- State ylffpE&Dow <br /> Repair Work Done ❑ Type of Pump Sealing Material (tol ---------- <br /> Well Destruction J Wer Diameter Filler Material (Below 5(r)Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLAT REPAIR!ADDITION DESTRUCTION t 1 (No�septic thm�feel I N public sewer is <br /> Installation will serve: Residence— Commercial Other O <br /> Number of Irving units: _ Number of 113801100mis F . i Water table depth <br /> Character of soil to a depth of 3 feet:. CaPsc tv No. Cpnpartmants <br /> SEPTIC TANK O Type/Mtg eeelltvd of Dispose w <br /> PKG. TREATMENT PLL ❑ Property Lame I <br /> Orstnre <br /> ce to neast: Well Famdation <br /> "raw�f G <br /> No.&Length of lutes 'S 10=7- <br /> LEACHING <br /> T — <br /> LEACHING LINE - Property Lee <br /> FILTER BED Distance tonearest: Well-� <br /> ourldetioh <br /> _ �� � Nurnlber <br /> SEEPAGE PITS ; I Depth property Lee <br /> SUMPS L I Distance to nearest <br /> Web Foundation <br /> ws, and <br /> DISPOSAL PONDS i <br /> I hereby certify Mat I have Prepared his application and that the work wa{be done irr accordance with San Joaquin�county ordinances,�issued, lashad not <br /> pr"Rtr"icx. rtramxice of de work far v6**-h this Per <br /> rules and regutaopro Of the nYs JoaquinL�Fed�(Growing: ••I certjly that in the pe <br /> Home owner D,licnsed age ap t to workmen's compensation laws of Califomua."Contracwls hiring or to workman's cornpnsa- <br /> amploy any person in such manner,as to become blec I,shWl employ t�rswls subject <br /> certifies the foaowing:"I certify that in the performance of Me work for which this perrWt a issued. <br /> tion laws of calwi ia." Cate drawug on reverse.side. <br /> The applicant must Gaff far requued eurpsctgrts. Deal <br /> /l -'� Title: <br /> Signed X y /- <br /> pARTMENT USE ONLY `. <br /> Fill <br /> AMS Vf <br /> °ase / r-/6 �9 <br /> Application Accepted by % Dals <br /> Data Fl inepecvon by <br /> Pit or Grout Inspection by <br /> Additional Comments: 0 Mameu .877104 - 0 Tracy <br /> 0 Stk 4666781 0 Lodi 381-3621 160( E. y{azNtvn Ava.. P.O. Box 2088.Sells CA StilOt _ <br /> Applicant - Return all copies to: Environmental Health Permit/Servicas <br /> RECEIVEDeY DATE <br /> ►dtetr'tEo. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH l <br /> INFO tpa1 <br /> o <br /> . EH 1}y11PEv.!/x51 <br /> EH 1416 <br />