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APPLICATION FOR PERMIT � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE_, STOCKTON. CA <br /> Telephone (209) 4664M1 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application ib hereby made io the San Joaquin Local Health District for a pefrrlit to Gor*truct arrdror install the work herein desCr4lye4• TIw sapfit*dvn is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage o.No. 1EI52 for wail/pump and the Rules and Regulations of the Sort Joaquin <br /> Local Huailh District. ? [� <br /> Job Address �`^ Rr t al City Cl CJC OJ.a Lot Sine 4 PEW <br /> {]worn': Name _i— Addrex �J�! —. '1.=" rl� PhWM <br /> I � I <br /> Contracttx r Address a License No. <br /> TYPE OF IMELL/PUMP: NEW WELL ❑ WELL REPLACEMENT f__1 DESTRUCTION ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR LJ OTHER F1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP_ LINE <br /> FOUNDATION AGRICULTURE WELL _ WELL_ PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS ION SPECIFICATIONS <br /> U Industrial Open Bottom i7 Manteca of Well Excavation __ pia- of Wo Cmwg <br /> C1 DornesticfPrivsto 7 Gravel Pack C I Tracy Type of Ceerny_ Specifications <br /> Public L Other Del Depth of Grout Seal Type of Grout <br /> Irripadon �pprox. Depth astern Surface Seal Installed by <br /> Repair Work Dery _ Type of Pump _ H.P, State Work Done _ <br /> Well Destruction i Well Dieme Sea <br /> Material stop G(I'} <br /> Depth . Filler Material )Below 59'1 <br /> TYPE OF SEPTIC WORK- NEW INSTALLATION PAIHIADOITION 9 DESTRUCTION U 4NQ septic system pernined if public erom is <br /> �// � aaaiWhirr Within�feeL.! <br /> Installation will Flares: Rserdence _ Comrrwrc+al ! [)[her <br /> Number of loving units: Number of bedrooms <br /> Character of roll to a depth of 3 leet: e4-8i WWN Obla <br /> depth <br /> SEPTIC TANK Q1"TvWMtg —Lw - P _ Ca No.No. Carpsirf»wKa L <br /> i KG. TREATMENT PLT. L#fl- 1�,,.. l� al�M <br /> f)iaance m naereab: 1N■M Foundation Y Litre- e>r } <br /> LEACHING LINE [ Flo. &Length of hires UO ' T taI EarrQlhleixa r <br /> FILTER BED f'tyDistenee to nearest. Wail 130 I Feundai4on Fg Property Line <br /> SEEPAGE PITS Lai--Dopth Size r' Number <br /> SUMPS ;1 Distance to nearust Well _L211 r Foundation _ f_ Propeny Line L� <br /> DISPOSAL PONDS 1 <br /> i hereby certify Ehnt I have prepared chit application and Etter the woric will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Son Joaquin LDCall Health District. <br /> Home owner or Iicansed agent's signature fortifies the Iosowing: "I certify that m the performance of the work far which iri4 permit is Issued, I shall not <br /> employ any person In such manner as to become subject to workman's ppoXxenastiun Iaws of Caldoinra-"Contra CEUe's hiring or sut}conlractinq signature <br /> Certifies the following: "I certify!flat in the performance of the work for which this permit is issued, I snail employ persons subject to wor rnan's cornpnnea- <br /> tion laws of California_" <br /> The appli7��W_ <br /> trad inspections. Complete drawing on reverse side. <br /> Signed x Title: --J--LslcL"t Data: y `� <br /> FOR DEPARTMENT USE ONLY kl&7 <br /> Application Accepted by Data At" <br /> Pit or Grout Inspection by Date Final Inspection by#A Date cr <br /> Additional Comments: _ <br /> CJ SIk 455-M1 n LAd 3W3821 IJ Manteca M-7104 ❑Tnrcy W545M <br /> Applicant - Retum 411 copfa/lq: Environm►ental Health Perr UServion 18151 E. Haaeilon Ave., P.O. Boa 2008, Stk_, CA 95MI <br /> FEE INFQ AMOUNT❑UE AMOUNT RE#AEiTED CK <br /> CASH RECEIrm BY PATE �PERMIT-No. <br /> Eli 13,24 IREV + n si �f LJ-Y 11 Yam! f � <br /> EH R47e / Q ff <br />