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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE4iON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �iComplete in Triplicate) <br /> Application is Iwieby made w the San Joaquin Local Health oisirict for a permit to construct andlor install the work herein dascrubad. Tfn6 appl,cat•Un is <br /> made In coniplianeeu with San Juaquin Cuurrty Ordifianq No.549 fur sewage a No- 1862 lot wall/pamp and the Rules and Regulations of the San Juaclwo, <br /> Local Health DtstFIGI. <br /> Jub Address _ � kAL . City �� Lot Site Dd ' PM <br /> Owner's Namea Add+ustr phone <br /> Contractor " c-c AOdresS 12f.71 eq( License fYo.z0_ Phane 36 3F <br /> 33 <br /> TYPE OF WELLIPUMP: NEW WELL CJ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PFTSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Induatrial M Open Bottom 0 Manteca Dim. of We11 Excavation Die, of Wall Casing <br /> ❑ DamesuclPrivale C Gravel Pack Ci Tracy Type of Casing Sptttcifiratiorra <br /> r-1 PUNIe Cl Other ❑ Delta Depth of Grout Seal Typo of 11rout <br /> I I Irl"tion —Apprntc Depth I I Eastern Surface Seal Instakad try _ <br /> Repair Work pone L] Type of Pump H P. State Work Dune _ I <br /> Well Destruction 71 Wail Dornotar Sealing Material Irop 501 <br /> Depth Filler Material 18alow 6D'l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION HCPAIRrADDITION I I DESTRUCTION I I INo septic System pttrmuted if public sewer us I <br /> available within 2DQ faet.l <br /> Installation will serve: ResKWnca Commercial _ that _ _� <br /> Number of towng units- _L_ Number a r ems �y <br /> Character of sod to a depth of 3 feel: — Wrier table depth I <br /> SEPTIC TANK W T"IlI fQ c ' 6 Capacfty No- Compartments <br /> PKG. TREATMENT PLT.0 <br /> 1 , Mathod of DAPO.Sal <br /> iDirrfanee to nearest: Wall • Foundation d25" Property Line <br /> LEACHING LINE 'Cr—Na_ li Length of litres � Total Iengthlsiae <br /> FILTER BED 13 Distance to naarast: Wail Foundation r 20 — Property Line <br /> SEEPAGE PITS L-w-depth � SIH r[llNumber <br /> SUMPS I OisraneA to nearest: WW S,01 Fouredasion _�LI Properly Line _ <br /> DISPOSAL PONDS <br /> I huroby certify char I have preparod thus applicatwn and that the work will be done in accordance with San Joaquin county rxdrnances, state Caws, and f <br /> tule5 and raijulations of the San Joaquin Local Ha filth Dt3rruci. <br /> Home uwner or licensed agent's signalure certifies the faAowtng: "I certify that in the performance of the work for which this permit is assued, I shall nor <br /> employ any parson in such manner as to becun`ie subject to wurkman's componsation lawn of Calcfdrrva." Contractors hiring or suto—c tntrocUng signature <br /> c01111105 the following: "I camly[Nat 14 Ihb pertormanae at the watk fat whirl's thts pprrNj is tlu,ed. I)halt ethpl0y petr✓ine Subtet:t to wwluman's campensa ' <br /> Lion laws of California." <br /> The applies mull call f all gwrod InLpeGtlanf. Campla[a drawing of�ty►rrefvfer�se side. <br /> S iQned 7t Ti11o' { r+[1 _ --- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Appltcmtton Accepted by Date — Area C2 <br /> Ptt Grout Inspe,clson by a Final Inspection by Data <br /> AdDuttonal Corrunents: <br /> 0 Sik 466.67BI ❑ Lodi 3n302r D Manteca 823.7144 1—) Tracy 05-OM <br /> Applicant Return all Copifl EnvirannWtal H4slth Perm,tlSorweas 1601 E- Ha;alton Ave., P.Q. Epx.x", S.W. CA 96201 <br /> FEE AMOUNT plJf AMOUNT REMITTED CK RECEIVED BY DATE PERA fT NO <br /> jHFp CASH <br /> 4 EH tiLr IFAV.ire 41 ��/r G . {f / <br /> 9H W� <br />