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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 1601 E. HAZELTON AVE., STOCKTON, CA <br /> �• Telephone (209) 466-6761 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> YT ' <br /> 3 .,- (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application a <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1832 for well/pump and the Rubs and Regulations of the Sen Joaquin <br /> Local Health District. . I - ' <br /> Job Address �2 �r LL�n�tn - . . ,. t. city- — Lot Size - - PM <br /> 1 1!r {/o9r5 j W,*i df <br /> - 0vwrnere Nana S�1?1N i` L�flk Address 11 31 m r,r�Q0 Gf— Piwna <br /> Contractor Address License No- 7 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ r { WELL REPLACEMEN.❑ DESTRUCTION ❑ <br /> - _ PUMP-INSTAtLATION�G�SYSTEM-REPAIR*S!—"'^^""^—OTHER-E], --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ; ETHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBCEM-AREA--CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ OpenBottom _ Manteca j Dea:of Weil_Fxcp_vatidn Die.of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Spadficati0m <br /> ❑ Public '0 titherYrDeTta------Depth of Grout�bea'I Type of Grout <br /> _ ❑ Irrigation ' _—LA 1. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Cl Type of Pump f H.P. State Work Done <br /> ♦ .T \C' iI �.f i <br /> Well Destruction ❑ Well Diameter,-- Searl"aterial ttop 50'1 <br /> O Otln Filler Material(Bebw-50'1_ { <br /> TYPE OF SEPTIC WORKA NEW INSTALLATION 5F REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sever is <br /> V t` r _ available within 200 feet.) <br /> Installation will serve: Residence/JJ Commercial_ Other ` <br /> Number of Irving units:� Number of bedrooms� _ <br /> Character of soil to a depth of 3 feet��. ! ���'�, Water table depth <br /> . SEPTIC TANK Type/Mfg ' Capacity 16 on_ No. Compartments <br /> PKG. TREATMENT PLT.❑ ,r... 1 �+.� / L' Method of DNosal <br /> Di nce to nsarrt: (W811— Foundation--�Property Line <br /> LEACHING LINENo.'8�C`ength of bane's=3"��`�S�iIS ,,T�6_{b�'lergdn/sea <br /> ' FILTER BED ❑ Distance{'[o nearest: a-AWall ji ad-- Foundation •_ Property Line _ <br /> SEEPAGE PITS ❑ Depth _I Size Number <br /> SUMPS ❑ DiAnce,to nearest: WellI Foundation Property Line <br /> DISPOSAL PANDS 13i r I <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,stele laws,and <br /> rules and regulations of the San Joaquin Local Health District. r Lr. <br /> Home owner or licensed agent's signature'car0m the following:"I certify that in the performance of the work for which this permit is issued, I shall rat <br /> employ any person'in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sufxomracting signature <br /> certes the following;"I cer,Qfy that in the performance of the wofk for wfnich this permit is issued,I sltaN empty persona subject to workman's aortpersa- <br /> tlon laws of California. <br /> r 3 <br /> The applicant must call foralllll squired inspections. Complete drawing on reverse side. . <br /> Signed)rri�c(( I Trde: I Data: --�� <br /> E POREPARTMENT USE ONLYt/, Area D <br /> I. I Date <br /> Application Accepted by <br /> k Pit or Grout Inspection by �' •Date I Final tnspeation by Dete� <br /> r � � � k Rr .. t <br /> Additional Comments: r <br /> ❑ Stk 4615-8781 ❑ Lodi 33621 ❑ Manteca 823-7104 ❑Tracy 835-SM <br /> Applicant-Return all;copies to: Environmental Health Permit/Services 16D1 E. HazalMn Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FFE AMOUNT DUE�_ AMOUNT REMITTED ' CK CASH RECEIVED eY DATE PERMIT'NO. <br /> { INFO <br /> 11 .EH13a11REV.1/esl ��, <br /> EH Ilia <br /> 1 <br />