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i.' , 4 . 4 . :4 , AFPYtATION. F9R ,PERIVIIT,..t...:,.., ,
<br />SANJOAQU,Ili. LOCAL HEALTH DISTRICT
<br />1601 E. HAZL:TVN''AVE.., STOCKTON, CA
<br />c' -Telep1ig.(209) 46616781
<br />, 11' PERMIT EXPIRES 1 YEAR'FROM• DATE ISSUED C: so et
<br />Local Health District: :••• .4
<br />Application is hereby made to thiSan 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. 549 for sewage or No. 1862 for well/pump and the Roles and Regulations of the San Joaquin
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<br />Citc•iliAthriVi Lot X3C)OPM
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<br />Address • • ' Phone
<br />License'No357 LIR a.- Phone cr
<br />WEel: REPLACEMENT'O DESTRUCTIONEl """`-----a"""'"-*--"'—'
<br />SYSTEM REPAIR 0 OTHER C7
<br />SEWER LINES DISPOSAL FLD. PROP. LINE
<br />AGRICULTURE WELL OTHER WELL PITS/SUMPS _
<br />•
<br />Depth•
<br />LEACHING LINE la.....No.k & Length .of lines-,LL,/4 - SS' ! • 1 Total length/size / 1c:
<br />. / FILTER BED El Distance to nearest Wel ;r Foundation
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<br />/Property Line
<br />, SEEPAGE PITS ; ,e..1 ; ••, n . 1•f-, + 1.-43-epthlt -• .0,,:TY'.0--, size's i ,W'r3 .'-. Number
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<br />- - --' ! SUMPS .7T.3 •J Eliv Distancr,e; to n,eare$t $, WelInii 5-0 Foundation /•,.7(*) Property Line 1 — I 1, 1%,: • ' . DISPOSAL PONDS Cr 4/1 `717`\ •-•3!.-N • '''t* -. ‘e- , -. .
<br />41 herel4 certifyqhat I .Aave prepared thli-app"licatiOri:a• rid-4114thri:Wiiik. Will be do.nit In accoraanawith San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Healih'Disiiict. : \ . •••-. ,
<br />, Home owner or licensed agent's signature cediflei the following: .'•;I certify`.that In the performance of the Work for which this permit is issued. I shall not
<br />.1 employ any person in such manner as to becoke subject to workman's Cortipcinsation laws:Of California." Contractor's hiring or sub-contracting signature
<br />Date:
<br />Application Accepted by
<br />Pit or Grout Inspection by
<br />Additional Comments: ••i
<br />El Stk 466-6781 0 Lodi 369-3621 In Manteca 823-7104 0 Tracy 835-6386
<br />Applicant - Return all ,copies to:/Eny1ronmental4frialth Permit/Servicesigoi E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 C. et4.• r•-• • k
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<br />Job Address
<br />- Owner's
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<br />l',41ame ...‘_.Lee__•, wrtA6,LEQ_t__. A. is. ..
<br />Contractor L E 6.,
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<br />Iktt-Address ,
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<br />-------TYPE-OrWEll-/PUMPI-------t—'"NEWINECL:70
<br />I PUMP INSTALLATION El .,.
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<br />DISTANCE TO NEAREST: SEPTIC TANK
<br />*/ FOUNDATION •
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<br />( TYPE OF SEPTIC WORK: NEW INSTALLATION 19--ftEPAIR/ADDITION q
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<br />DESTRUCTION CI (No/Septic sy'stem permitted If Public 'sewer is -
<br />, _ . available within 200 feet/ 0 .1
<br />' nstallation will serve: Reaidenice ._%-....---"Commercial ._..her r , 4 -
<br />/ • -.
<br />, Number of living units: _/.-.._. Number Number of bedrooms ,
<br />Character of soil to a depth of 3 feet: Water table depth
<br />eSEPTIC'TANK 0 Type/Mfg CO IL 61--E, Capacity .4a too No. Compartments ',=•••••..... .1 ,i,.. ''PKG.•TREATMENT PLT. I:1 n . I Distance to nearest: Well /00 Foundation I L.) .13'roperty Line /00"7 '1 ,-.. ( 4 .. .
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<br />Ofi i Method of Disposal
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<br />i Well 6estruction 0 Well Diameter
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<br />INTENDED USE -TY& OF WELL...—PROBLEM.AHEA,-..CONST.RUCTION.SPECIEICATIONS
<br />1 0 Industrial CI Open Bottom CI Manteca •<---Dia, tof.Well•E?tcavation Die, of Well Casing
<br />I 0 DomeltIc/Priyate El Gravel Pack 0 Tracy Type of Casing Specifications
<br />I 0 Publi/ 0 Other • 0 Delta Depth of Grout Seal --- . :._ Type,of Grout
<br />.........
<br />) i 0 Irrigation • _Approx. Depth 0 Eastern Surface Seal Installed by
<br />Repa Type ir/Work Done 0 Ty of Pump H.P. State Work Done i .fr./
<br />... •
<br />Sealing Material, itoP EV I —
<br />1 Filler Materiel' 501 i . ..
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<br /> ' c ' lea the following: ' ify that in the • :riorniance of the work for Which this permit is issued, I shall employ persons subject to workman's compensa-
<br />. The applicant
<br />tio-rila
<br />call for all
<br />If , c...... 1 Ats:.` , ,,er -.1 `\ California.'
<br />i‘ith,„„,„„,t . : . , 1114, litse drawing on ' erse side.
<br />I ,Signed W i i b. . W 2 g I I I II . ...' -;•.. .4 .11....- . le:-
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<br />FOR PEPARTMENT USE ONLY -
<br />1 l' - 1 . Date 75-
<br />a ir (rije-45-Final Inspection by
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<br />.E 13:24 8 b) ',EH '
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<br />FEE
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<br />i AMOIJNTIDUE ANDLINT REMITTD E " --ElfLAD ,..,- CASH , RECEIVED BY ., DATE PERMIT-NO.
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