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-t-t-LFUATIUN FOR PERMIT
<br /> ". SAN JOAQUIN LOCAL HEALTH DISTPJJ�T
<br /> k 1601 E. HAZF,L T ON AVE., STOCKTON,
<br /> Telephone (209) 466-6781 — t
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> {Complete in Triplltatel -- �
<br /> Applrcarlon is hereby made to the San Joaquin Local Hearth Ilistrict for a pnrm,r to construct and/or install the work herein described,This application is
<br /> ti made in compliance with Sen Jnaqu;n County Ordinance No,!i49 for sewagtr or No.1862 for wellipump and the Rules and Regulations of the San Joaquin
<br /> Local Hoalr,h District, y
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<br /> JobAddr,tss �J`�,Jt7 ��ir0/1K5 �
<br /> _ City Tr I Litt Sire PM
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<br /> Ow,wr's Name Address _0,444 Phone -- - t
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<br /> Conlraraa . L _ Address _L'Censa No.�
<br /> �5'V_Phone
<br /> :y' - TYPE'.)f WELL/PUMP: NEW WELL 0 WELL REPLACEMENT (U DESTRUCTION 0
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<br /> PUMP INSTALLATION ❑ S,STEM REPAIR 0 OTHER ❑
<br /> DIST4NCE TO NEAREST: SEPTIC TANK SEWER LINES .` DISPOSAL FLD. PROP, LINE p�
<br /> FOUNDATION _ AGRICULTURE WELL _ OTHER WELL PITS/SUMPS
<br /> .E INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> 41
<br /> 0 Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation pis,of Well Casing
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<br /> 0 Domest,ciplivate n Gravel Pack 0 Tracy Type of Casing Specifications
<br /> . �3Zi ,^ NPublic ' II Other i"1 Delta Depth of Grout Seal Type of Groul
<br /> .71. } _ ;!'+Irri(lation, •T,Approx.Depth I I Eastern Surface 5a.,1 Installed by
<br /> Pepair Wok Oone (J Type of Pump
<br /> H.P. orate Work Dana_
<br /> INeM Destruction d Mull Oian�ler Sealing Material{top 501 ,
<br /> +r Depth Fillor Material 18elow 501 _ F;
<br /> TYPE OF{SEPTIC WORK* :NEW INSTALLATION! (
<br /> REPAIR/ADDITION7 DESTRUCTION I I INo septi[system permitted if public sewer etc
<br /> a1 ), , i' available within 200 feat.] alt_ 4 f
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<br /> P','MV !. tnatellatbn will serve: Residence f Commercial._„_, Other
<br /> rssri i *1 r w a
<br /> Number 4,f living units: 1 Number of bedrooms _ .
<br /> �x t c !�
<br /> r. ;} -Character of Sart to a depth of 3 feet:.A, ��0�4+J_ Water table depth �C
<br /> SEPTIC TANK 0 Type/Mfg Canaci y�6
<br /> N No.Compartments p
<br /> PKC TREATMENT PLT.C] Method of Dispose] t""may
<br /> !; ' Distance to'nearrltt: ` Well �O -. i
<br /> Foundalion Progeny Line ! 2" ! .1>�,'
<br /> LEACHING LINE ;.121 No.8 Length of lines 'ole]length/size' /tle '_ K
<br /> FILTER BED+, 0,:Distance to nearest, Well��` Foundation Property Line
<br /> SEEPAGE PITS I i 5 Depth ° Size Number Rt
<br /> 'SUMPS 11 Distance to nearest:? Well foundation Property Lina
<br /> r wh r DISPOSAL PONDS. 1J
<br /> 1 hereby Certify that 1 have prepared this application and that the work wRE be done in accordance with San Joaquin County ordinances state laws and 1A
<br /> rules and regulations of the San Joaquin Local Health�Diktrict.
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<br /> 4y -retic zed
<br /> r �< Ha ovyrter or IrcersseafJent'
<br /> d s signature certifies the following,"f certify that in the porforrxk ence Ort the w, for which Wm
<br /> this is isatrad,l!Shoff not r wl�rt
<br /> employ any os Ion In such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sab•cortnechng signature•i
<br /> certifies the following '7 cartify that in the performance of the work for which this pormit is Issued,I shall employ persons sub(eet to workman s etxmpenssp"". a
<br /> tion laws of California" ?� t i
<br /> The appfresnt� st call for ail required inspections.Complete drawing on reverse side. - s t ,v
<br /> r " Signed% t Title: bate
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<br /> r&y t -•t}
<br /> FOR DEPARTMENT USE ONLY / `W
<br /> Appfecstiort Accepted by... •_ - Oeta 's
<br /> ?•' , 5 .. fee'
<br /> Pit or Grout 1neKactlon by Date Final Inspection by �u��D to,5 Q�^
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<br /> l ' Salt Additional Comments:
<br /> a L 4 r,'0 Stk.:168.6781 0 Lodi 369.3621 Cl Manteca 8M-7704 ©Tracy 83S-B385 r
<br /> e _Appncent Return all copies to:Environmental Health Permit/Services 1601 E.Hazelton Ave.,P.D.Box 2004,Stk.,CA 95I01
<br /> ^ -� Y• i. ,S .FEF. AMOUNT DUE AMOUNT REMITTED
<br /> INFO. K RECEWED BY DATE PERMIT NO. jre
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