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APPLICATION FOR PERMIT <br />X. 'rr. ti <br />LTH DISTRICT <br />SAN JOAQUIN LOCAUHEA <br />1601 E. HAZELTON'AVE., STOCKTON, CA <br />Telept�one­(2091468-68f <br />PERMIT EXPIRES 1 * YEA13'FR6M. DATE `ISSUED <br />-1 <br />(Complete iriT,r*ipficate)" I. ;m; .., _. <br />�,,q 1-110 <br />7 :" , .: . , J,. ' cll,a;jllt ;-v_, <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct arid/or install the work herein -described.: Iwo -application is <br />made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump andthe Rkilles, and Regulations of the San Joaquin <br />-Local Health District. <br />14 grit ez;, <br />Lot She <br />Address PM <br />Job <br />1;4 i.ir-PIS w <br />g, —Phone <br />0whdr's Name 0, .72 <br />Contract Cd Address License No. TV ;I ;Z Phone -T16 -Y s"i9' <br />TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT'O DESTRUCTION LJ iC <br />PUMP INSTALLATION 0, <br />DISTANCE TO NEAREST: SEPTIC TANK'. SEWER LINES DISPOSAL FLO.— PROP. LINE <br />rl <br />OTHER WELL-----. PITS/SUMPS i <br />FOUNDATION AGRICULTURE WELL 0 <br />INTENDED USE <br />0 Industrial <br />0 Domestic/ Private <br />0 Public <br />D Irrigation <br />Repair Work Done 0 <br />Well Destruction 0 <br />-� <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFItA171ONS <br />• Open Boitom i 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br />• Gravel Pa'ck 0 Tracy. Type of Casing — Specifications <br />• Other 0 Delta Depth of Grout Seal Type of Grout--i- <br />---Approx. Depth 0 Eastern Surface Seal Installed by <br />Type of Pump H. P. s State Work Done <br />Well Diameter <br />�1' Seating Material flop 501 <br />Depth Filler Material 4("ow 501 <br />TYPE OF SEPTIC.WORK: NEW INSTALLATION Z' REPAIR/ADDITION 11 DESTRUCTION 0 (No septic system permitted <br />availablewithin200 feet.). <br />Installation will serve: Residence C dmmsrcial_ Other <br />Number of living units::_ Number o V_ roorr4 <br />Character of sail to a depth of 3 feet- Water table depth <br />SEPTIC TANK # LP- Type/Mfg Mkgi�l Capac- ;No. Compartments, - <br />PKG. TREATMENT PLT. 11 Method of D*rosa - <br />Distance,to nearest: Well 100 Foundation Property Line <br />LEACHING LINE. I0 No. &>C4ngth 6f fmas J Tdial Ien1gth1siie <br />' '. f i $. � " ",Foundation FILTER BED 11 Distance to nearest: Well, ------ Fo Property Line <br />SEEPAGE PITS Zr- Deprth.,.,4: Size� �,, Number <br />SU MPS-- Distance to nearest: Well ift f&O Founda�6n '66 Jf, Property Line 5" <br />DISPOSA[46NDs' 0 <br />I hereby certify fiiat%i have prepared this appli <br />rules and regulations.of; tl4s San Joaquin Loc <br />Home owner -or licensed'a46iWisignaie cer <br />smplWiKylerioh -in such manner ag'to=beco <br />certifies the following '-1certify . that in tl' e per <br />tion lava of California.." <br />The applicant st call for -01 ranuffnedl inset <br />Signed X <br />A94 <br />Application Accepted by <br />Pit or Grout Inspection,.by <br />Additional Comments.* - <br />0 Stk 466 -Ml ;0 Lodi 36§-362? <br />Applicant <br />OP <br />EH 13-Y (REV. a/86 <br />EH 1426 <br />id that the work will, be done in accdrdaric <br />District. <br />foi&ihg. "I cerfify';ha�ne i—perfbrrnari <br />nt to wdrkrnanls compensetion lawsof Cal <br />of the vArk for winch this permit is issued <br />impletii-drawing on reverse sir <br />.� - <br />T . " _k <br />�. .: ;;; - FOR DEPARTMENT USE <br />sewer Is <br />P <br />JA <br />D'with San Joaquin county ordinances, state laws, an <br />e'of theWork for which this permit is issued, I shall not <br />fomia:Q,Con4l�ctor' i hiring or sub -contracting signature <br />4 shall ern <br />.)96pesons ' ' N workman's comP <br />,y su ject to ensa- <br />Date Final ln*30e06n by <br />zi Manteca e23-7104 <br />"Ith e - rvim 160 F. Stk <br />,�jt�n�, Bo�c 20M, rA <br />.7 <br />A7 <br />201 <br />CIC �ECEIIVED BY. DATE. I PERMIT NO.;' <br />��,FjfE <br />public <br />FEE <br />AMOUNT DUE.' <br />AMOUNT REMITTED <br />CASH <br />o I <br />-, <br />t <br />CA-- <br />E, <br />