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APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Fri,
<br /> 1601 E. HAZELTON AVE.,STOCKTON.CA
<br /> Telephone 12091 466-6781
<br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED
<br /> - ENV1r,-_1.Q HLALIH
<br /> (Complete in Triplicate) I"ERM!I/SLW!!CES
<br /> Application is hereby Ontaks to the San Jc.q.in Local Health Oisiricl for a pinmil to consu,cf."/or install the work he,,,,described,This application is cornOwwo with San Joaquin County DOlmanco Nu 549 lot sewage or No 1862 to,wellIp—p and the AId-and Regulations of the San Joaquin
<br /> L.,id Health D..nict.
<br /> Job Address rN S! &) I F tr, RJ Ci,,Ain z AA P,
<br /> If.-,'.N.— B:R tj. < Address j� I kA !S,,
<br /> — S L!(I.— ___Phone
<br /> Conftac(/��- S�Address I Z Y&Y 1 -5 rc,C lense rqo/ g .P�W v
<br /> TYPE OF WELLIPUMPL NEW WELLWELL REPLACEMENT 11 DESTRUCTION 11
<br /> PUMP INSTALLATION El SYSTEM REPAIR [I OTHER 11
<br /> DISTANCE TO NEAREST: SEPTIC TANK—SEWER TINES DISPOSAL FLD._PROP.LINE i
<br /> FOUNDATION AGRICULTURE WELL __OTHER WELL.PITS/SUMPS
<br /> 1,F;4 rNTFNfIrD U$L TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> P
<br /> L I industrial
<br /> e` ii, A-15pen Flattorn
<br /> 0 Manteca Cie.of Well E.—tron Dia,Of Well Crethg
<br /> I Domestic/Private Cl Gravel Park 0 Tracy Type of Casing 57Ak Spec.ficat—
<br /> I I Public C]Other F-I Didui Depth Of Grout Seal A
<br /> 4-rr,,,O.n __Approx.Depth I I Eastern Surface Seal Installed by
<br /> Repair Work Dn. Ll Type of P.rnp_r%ilt_t�f N H.P. State Work Done
<br /> Well Destruction 1 1 Well Diannal., — scaling Male?W(top 50.1
<br /> Depth— Fidler Material Iflakow 50'1
<br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I lNo septic system P.—Ited If publit,..we,is
<br /> 'Vifil.64.within ZOO feelI
<br /> Installation will serve: fletsid—ce-_ Commenciall_ Other__ t
<br /> I
<br /> Numblivingbe,at living nits: Number.1 bedrooms
<br /> Character Of soil IG a depth of 3 fear: water table depth
<br /> SEPTIC TANK n Type1Mfq Capacity— No.Compannients
<br /> PKG.TREATMENT PLT Ll Method of Disp—rd
<br /> Distance To nearest. Well Foundation--._Property Urn,
<br /> LEACHING LINE 11 No.A Length.1 iines Total length/tiiza.,
<br /> FILTER BED Distance to—eav Well Fo..d.t——Property Lin.
<br /> SEEPAGE PITS I I Depth Nurn't—
<br /> • sumps I V Ditifii.c.to—-P Well Foundation—Property Line
<br /> DISPOSAL PONDS I
<br /> I hunibY candy than I have PI-runed this application and that the
<br /> work will be done in acc—ElOw with Set,Joaquin county ontin,ances.state laws,and
<br /> .ns and regWatrons of the San Joaquin Local Health District
<br /> Home owner or licensed agont',I,signature canities the following:"I candy that in the peftrinancit,of the work for which this permit 6 issued.I"it not
<br /> "101v anyparsonin such—nal as To become subject to workman's compensation Laws Of California."Contractor's hiring or sub-conna.ting signaturec—ifi..the 10110-97"1 candy that in the performance of the work 101 which this P-11nif i—I.Id,I shall—ploy persons subject to worknuin'....p..sa
<br /> lion laws of California."
<br /> The aPPhcan,—.1.0 for an required Inspections.Complete drawing On reverse side.
<br /> Signed X� A J
<br /> Title:_CEI 1, Date: jv,
<br /> FOR DEPARTMENT USE ONLY
<br /> Application Accepted by 7�tl"f) A
<br /> Pit Or Grout Inspection by Date—Final fropenion by Date
<br /> Ad&Ti—I Cona—,
<br /> 6 j"Sulk 466-6781 0 Lod, 369-3621 171 M.rdec,ii 823-71D4 11 Tracy 835.&IM
<br /> pitcard Return all copies to:Environmental Health Permit/Services 1601 E.Hazillitch A,,tr,P.O.B..20119,Stk.,CA 95201
<br /> NFO AMOUNT DUE AMOUNT REMITTED Y-A�S4 RECEIVED BY ATE PERMIT NO.
<br /> S-7 1-7CnI
<br />
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