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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.--I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM'DATE'ISSUED HEALTH <br /> tiEAL <br /> (Complete in Triplicate) [r 0 RMIT�SERVICES <br /> ',-a qr­ e work Wlin described,This application is <br /> Application is hereby made to,the San Joaquin Local Health District for a permit to construct and/or install th <br /> made,in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ip <br /> Job Address CP_," s City <br /> ALot Size PM <br /> Owner's Name pit, OU-0-0 E�- Address i174A�972 Phone <br /> Contractor Addresi License No.3_?:a�_ Phone <br /> :FY-PE OF WELL/PUMP: NEW WELL: a WELL REPLACEMENT^ DESTRUCTION 0 <br /> PUMP INSTALLATJON Ll SYSTEM REPAIR 13 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL— PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR �A a CONSTRUCTION SPECIFICATIONS <br /> of W Dia..of Well Casing <br /> L] Industrial LJ Open Bottom 0 Manteca Dia: of Well Excavati —Ar— <br /> C <br /> Domestic/Private, Gravel Pack racy Type of Casino Specifications 6cl 017 <br /> X Kc. ;P—li- <br /> 0 Public LJ Delta Depth of Grout Seal Type of Grout 26 <br /> 1 0 Irrigation pprox. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done Cl Type of Pump H.P. State Work Done <br /> Well Destruction EI Well Diameter Sealing Material (top 501 <br /> 4 <br /> Depth Filler Material iBelow 51Y) <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if publicsewer is <br /> available within 200 feet.) <br /> (J) <br /> Installation will serve- Residence. Commercial Other <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> S <br /> SEPTIC TANK E Type/Mfg Capacity— No. Compartments <br /> p <br /> PKG. TREATMENT PLT. 171 <br /> Distance to nearest: Well Foundation Prop <br /> LEACHING LINE E! NO. &­Le.ngth of lines Total length/size AUG 3 0 1988 <br /> FILTER BED 0 Distance to nearest: Well Foundation— Property Line <br /> ENVIROMENTAL HEALTH <br /> Depth Size Number PERM IT/SERVICES <br /> SEEPAGE PITS P� <br /> SUMPS 171, Distance to nearest'. Well Foundation Property Line <br /> DISPOSAL PONDSi6-6'. <br /> I hereby certify that I have.prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the:San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mwl-rvlll for reWire inspections. Complete drawing on rev side. <br /> Signed X_ Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inspection by�lW za_;p" Date Final Inspection by Date <br /> Additional Comments: <br /> El Stk 466-6781 ff!,-Lodi 36-36�1 El Manteca 823-71 0 TraW 835-M A 9YO <br /> Applicant- Return al copies to: Health Perm' ervices 1601 E. He Ave., P.O. 8 2009 Stk.,F 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK 0 RECEIVED BY DATE PERMIT'NO. 4b <br /> CASH <br /> INFO 211 q 1 ,7C� 2-31231: <br /> 010 - 2- <br /> 0() "nq <br /> + EK 13-24 1 REV. 95) <br /> EH 1428 <br />