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� ,l <br /> r - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTUN, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to:Ite San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.509 for sewage or No. 1862 for well/pump and the Rubs and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address S�SO *",ARIArSq i2D City S77eAll Lot Size PM <br /> - -5Address Phone Gtr TT <br /> Owner's Name — <br /> Contractor __FC�tL? ![/O/D Address�7 rl, A�6t_RF.QT iK� License No.512:r �� Phone- 9 <br /> 71 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL FLD. PROP. LINE <br /> !t: FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONsTiweiim SPECIFICATIONS <br /> t. — <br /> ❑ Industrial O Open Bottom ❑ Manteca of WON Excavation Die.of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ❑Tracy Type of Casing Specifications <br /> ('1 Public i-1 Other n Depth of Grout Seel Type of Grout <br /> I I Irrigation Approx. Dept I Eastern Surface Seal Installed by - <br /> Repair Work Done 11 Type of Pu H.P. Stall Work Done— <br /> WeN Destruction l l Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material(Below 50'1 - <br /> TYPE nF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence-Z Commercial_ Other <br /> Number of living units: --�— Number of bedroums 7- Iv <br /> Character of soil to a depth of 3 Not: C A,4e Waren table depth__ <br /> SEPTIC TANK M Type/Mfg .5;� -+•It Capacity _ No. Compartments <br /> PKG. TREATMENT PLT.(1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line_ <br /> LEACHIiiG LINE ZNo. 8 Length of linest Total length/size <br /> FILTER BED [) Distance to nearest: W '1 so,, Foundation 10 r Property Line /D , <br /> SEEPAGE PITS IjDepth Site rr Number <br /> SUMPS i I Distance to nearest: Well /Op / Foundation ��r._. Property Line <br /> DISPOSAL PONDS (I <br /> I hereby certify that I have prepared this application and that the work wig be done in accordance with San Joaquin county ordinances state laws,a <br /> rubs and regulations of the San!csquin Local Hialth District. <br /> Home owner or licensed agent's signature cerjiflee tM following: "I ceRify that In the performance o +ase work for while t>,i�r� rseuv�. <t ag not <br /> employ an-person in such manner, to bet subject to workman's compensation laws of Co';fMn 'Contractor'-hi,inu t.g torture <br /> certifies the following:"I certify that in the performance of the work for which this permit is issue.: I sht:employ Pers: n wori man'•c ntyerwa- h <br /> tion laws of California." <br /> The applicant forall required in .Ions. Complete drawing on reverse side. <br /> Signed X;;52 `L Title: —LL7L — Date: 2 X2.4 <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by y/ �/ Datar21.` <br /> _]`-' 1�lL_ At" <br /> Pit or Grout Inspection by Date Final Inspection by y ' . � Onto 1 7 <br /> Additional Comments: <br /> L', Stk 466.6781 (, Lodi 369-3di ❑ Manteca 823-7104 ❑ Tracy 835-6.385 <br /> Applicant Return all copies tom: Environrr.ental Health Permit/Services 1801 E. Hatelion Ave., P.O. Box 2008, Sik., CA 95201 <br /> IEE AMOUNT DUE AMOUNT RFtV11TTEO K RECEIVED By DATE PERMITNot <br /> INFO —� <br /> . EH 1774 UtEv <br /> EH 1 <br /> t 74 <br />