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APPLICATION FOR PERMIT
<br />SAN JOAQUIN LOCAL HEALTH DISTRICT •
<br />1601 E. HAZELTON AVE., STOCKTON, CA
<br />Telephone (209) 466-6781
<br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />. (Complete in Triplicate)
<br />Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and/or install the work
<br />made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules
<br />Local Health District.
<br />herein described. This application is
<br />and Regulations of the San Joaquin
<br />Job Address c"---L., ,p .4...r , r7 /7 el1 c.-. r- ,-., Y /
<br />_ ,/
<br />.........
<br />1 ..
<br />Owner's Name n.c-1...,K e- 4, . z. <_,..— Adorw .2, 6 .6r—\ 7 ir./A,0-s e-iti phone .....
<br />1.. F-2, z_L--te..._ License No. 2 75-5... Phone .- ? 9 //‘'1 Contractor's Name , A
<br />TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0
<br />PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0
<br />SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE DISTANCE TO NEAREST:
<br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ .
<br />INTENDED USE TYPE OF WELL '' PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br />„
<br />0 Manteca Dia. of Well Excavation Dia. of Well Casing 0 Industrial Li OpenBottom
<br />0 Gravel Pack 0 Tracy Tyr" of Casing Specifications 0 Domestic/Private ...--,
<br />"' L Dia --- Dapth of Grout Seal Type of Grout 0 Public E Other
<br />Depth 0 Eastern Surface Seal Installed by 0 Irrigation .............Approx.
<br />0 Type Pump H.P. State Work Done Repair Work Done of
<br />0 Well Diameter Sealing Materiel (top 501 Well Destruction
<br />: Depth Filler Material (Below 501
<br />TYPE OF SEPTIC WORK: NEW INSTALLATION GI REPAIR/ADDITION C DESTRUCTION C (No septic system permitted if public sewer is
<br />i -. - ' -... 7,6 available within 200 feet./
<br />Installation will serve: Residence _101± 4 Commercial Other
<br />Number of living units: _ Number of bedrooms
<br />A De IT a"-- Water table depth Character of soil to a depth of 3 feet:
<br />Yr, trie/IctIg--13 4 4)---- Capacity --/i-idl — NO7Comrcartments -._ SEPTIC TANK
<br />A Method of Disposal PKG. TREATMENT PLT. 0 4 . .,-. , 9- .., sl , -occ--
<br />Distance to nearest: Well text'
<br />Ac-
<br /> - Foundation- .-// ' Property Linejo-
<br />.I -• .
<br />& Length lines 1. F7-- Total length/size ,.--16 / LEACHING LINE X., islo. of .1
<br />'9 to nearest: \ Well 9.1 e ../Toundation go Fr- Property Line. 15- Jc-r--- FILTER BED Distance
<br />PITS 0 Depth - ize . - ---1.-umb-ei:- A- 1 - ' \ SEEPAGE
<br />0 Distance to nearest: Well Foundation Prop‘rfy Line SUMPS
<br />niconc zi i Dflikl 11C 71 X .
<br />V......-.4 k y.
<br />I hereby certify that I have prepared this application and that the work will be done in aCcOrdance with Sari Joaquin count' ordinances, state laws, and
<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 iub-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 vvorkritan's compensa-
<br />tion laws of California." 1 \ , ....IN,
<br />The applicant must call for alit, uired inspections. Complete drawing on reverse aide.
<br />'--,'"'s'1,,,:t.:-,,,N 2 •
<br />- I k
<br />Signed X dai 1 -e(---7-Z---- ....4-4-1-A------ ..,-. Y
<br />
<br />t
<br />‘. - 'ride: --. --=-- Date•-r -10-ef
<br />rules
<br />t•T\I'r-
<br />and regulations of the San Joaquin Local Health Distr4ict.
<br />ii FOR DEPARTMENT USE ONLY
<br />Application Accepted by IV , l' _ Date A' 'it f . V. Ahia st7--.77
<br />Pit or Grout Inspection by ; • Date
<br />— -- iiil
<br />I
<br />/
<br />f
<br />. -^.. m
<br />Final Inspectien by ff W i Mg' Date C"
<br />Additional Comments. 1 A ......- ..--- -.....-- .....-
<br />U Stk 466-6781 CI Lodi - 369-3621 D Manteca 823-7104 0 Tracy 835-6385 ,N.e
<br />Applicant - Return all sopies to..,7! Environmental Health. Parit/Servicel 1601 E. Hazettor2 Av!...,.. P.O. Box 2009, Stk., CA 96201 _ ....
<br />'''' 'c rc
<br />EH 13-24 IREV. 10/831
<br />EH 14-28
<br />INFO
<br />..
<br />— -- -- AMOUNT DUE
<br />-,
<br />..- -''.-- - AMOUNT REMITTED t - CAS H - - - - --- -e" RECEIVED 13 --Oka-- • " Pteniffrio "
<br />146-00
<br />OA - N v 16-2.,frgit i).Li- 137 0
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