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t , APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • I 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 1 Telephone (209) 466-6781 <br /> ,PERMIT EXPIRES ?'YEAR FROM DATE ISSUED <br /> !! (Complete in Triplicate) <br /> 1 . <br /> mape Application is I compliance wmade h Sao the Joaquin io�Coution is <br /> nty Ordinance lNo.549 for Health District fsewage or or a INo-7862 for well/dpump and the Rules and 1Ragulatidescribns of the San. This r�oaQvin <br /> Local Health District <br /> ��Q'teCLot Size{() M T <br /> Job Addresr { (_Q <br /> Address y "v 1+ I Phone <br /> t <br /> Owner's Name�y�-- e� <br /> Contra r O'K ddress <br /> yr'� / alL7K License No. 2Z� Phan <br /> NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 ,a'.` •�T <br /> TYPE OF WELL/PUMP. SYSTEM REPAIR ❑ OTHER 0 " � +• <br /> .6 PUMP INSTALLATION ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. r PROP. LINE `. <br /> AGRICULTURE LINES WELL _ OTHER WELL PITS/SUMPS' — <br /> �— FOUNDATION <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE - ._. -- —' Dia- of Wellasir[gF j <br /> ❑ Industrial 0 Open Bottoms MantecaDia�of�Jell EacavaiwR—' <br /> Type of Casin Specifications ' <br /> 0 DomesticlildvaM 0 Gravel Pac' ❑ Tracy „ , t-� t Typa of Gro t_ <br /> f'1 Public ` <br /> ❑ Other O DehS ._--Depth,Of_Grout Seal:-:•: --- - I <br /> I I Irrigarione _Appro:- DePth l l Eastern surface Seal Installed by <br /> of Pump H.P. State Work Doney <br /> Repair Work Done ❑~ YPe Sealing Material (top 50'1 n <br /> Well Destruction 0f Well Diameter. <br /> Depth Filler Material(Below 50'1 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION �`REPAIRlADDITION LI DESTRUCTION 1 I INo septic system permined if public sewer is <br /> • available within feet.) p. <br /> Residence, <br /> 7—, 4!l Comrnerclal�, Other <br /> Insfel4ation will serve: Residence�r J; ,. <br /> 'm .Number o drobms <br /> Number of living unBs: _— water table depth r-- <br /> Charactet of soil to a depth of 3 feet:1 - i Capadty No. CompartmentsZ Z . <br /> SEPTIC TANK Type/Mfg r Method of Disposal <br /> M / <br /> PKG. TREATMENT PLT.❑ - <br /> V t/ Foundation Property Line <br /> Distance to nearest: well <br /> •' r / Total length/Size K <br /> No,illength ul Jinin <br /> LEACHING LINE, ♦ ♦ l <br /> Foundation — Property Line <br /> FILTER BEDS ❑ Distance to nearest: well-A <br /> •. �j. Ai'rt / r 1/ <br /> - Number <br /> • ./3. AGE PITS Depth Size ���� r <br /> .e ,g - "`/ Foundation-1Q-- Property Lina — <br /> SvSUMPS a ❑ Distance to nearest: Well <br /> ,r DISP,OSALPONOS `•7d - <br /> 1 hereby t'artify that 1 have prepared tRis app)kation gnd that me work will be done in accordance with San Joaquin county ordinances,state taws, an <br /> l not <br /> rules and regulations of the San Joaquin Local Health D3trict. 11 <br /> Home owner orr licensed agern�tnnegas[orbecome subject t �orkmann'sRcompensation lfity that in the am of California."Contractor's'h ri+g orrssub'contract ng signature <br /> ampldy any pe <br /> certifies the following:"I h man that s the performance of the work for which this permit is issued,1 shall employ persons subject to workmen's COrrtpen53- <br /> tion laws of.California." t - <br /> The applicant mus 11 for all re. 'ed in actions. Complete drawing on rave\�tp4•T DatA 660VSignedes <br /> Title: ) rN <br /> ;I FOR DEPARTMENT USE ONLY <br /> �— � Area�-(L-- <br /> Date g <br /> Application Accepted byDate <br /> r Grout IOapeaLlOn by <br /> are 4� insl inspection by <br /> _ VIS -, <br /> F <br /> � dtlitioml Camrnents: 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835.6385 <br /> _0 Stk 466-6781 Stk., CA 95207 <br /> ��Applicent- Return all copies to: Enviro�rnBrdat Health Parma/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> L <br /> G.z OK RECEIVED BY DATE PEflM1T'NO. <br /> r "I FFEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> T (P-21- lr�Y"tY7 <br /> c Ea 13.2t IRW.1/'51 ,0• ��/ <br /> EEH 14211 _ <br />