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1 � APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Cornple ff in Triplicate) <br /> Application is hereby made to the San Joaouln Local Health Dial for a permit to construct and/or install the work hemin described. This aptillcation It, <br /> made In compliance with San Joaquin County Ordinance No.Sag for sewage or No.1862 for well/pump and the Rule.and Regulations of the Satirical <br /> Local Health District. <br /> Job Address 1 12 log �r�••`.��-�""�' !�— Cm lm Size kill .— File— <br /> Owners � <br /> 9 A- <br /> /iz92T1•C� L�/ Phono <br /> Ne �a --- aa��'' ��.s(('''��/�p�� 1 <br /> Contractor Address A"-e License Now Phone/ l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wed EacavaboO. Dia. of Well Casing <br /> Domestic/Pi ❑ Gravel Pack ❑Tracy Type of Casing Specifications <br /> I9 Public n GiM, n Delta Depth of Grout Seal Type of Ell <br /> I l Initiation Apirmi Depth II Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type o1 Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material(tap 501 <br /> Depth Filler Materiel (Below 501 — <br /> TYPE OF SEPTIC WORK: NEW WSTALLATION REPAIKTADDITION-l I DESTRUCTION 1 I IN.seplic system permitted if public sewer Is l <br /> p._ available within 200 fast.) <br /> Installation will serve: Reeitance_ Commerill Other. APM— <br /> Number of living units: Number ofydL�puls 1'fol <br /> Character of mil to a depth of 3 leer. LAM ` ����^ Water tabb depth <br /> SEPTIC TANK B/Type/Mfg O r J,-'J fP Capacity L 00 NO. Compartments r"1 <br /> PKG.TREATMENT PLT.❑ +�JMM � Merhod ofDi possal <br /> Distance to rentalWella.L Foundation 92 <br /> 0 <br /> — Property Line 5 1 <br /> LEACHING LINE Fill 6 Length oHinra- 4 -'nTo/tal IeneN/size <br /> FILTER BED. ❑ Distance to reenact: r Wd1 y 6� Foundation Property Lim <br /> SEEPAGE PITS I Depth 2,S SiIf Jill; <br /> m p' Number ��r� <br /> SUMPS L1 Dist meaner. Well io mea Well3�J 11toureal f Property Lire Sw <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I heve prepared this application and that the work will be done in ecoordm¢e with San Joaquin county ordinances, state all and <br /> rues and regulations of the San Joaquin Local Health District. <br /> Hems owner or licensed agent's signature cartifies the following: "I c r ity that in the pernormmlce of the work for which this permit is mrsted. I shall not <br /> employ any person in such manrer as to become subject to workmen's compensation axe of Californal Conpac roes hiring or subcontracting signature <br /> terrifies the following: "I certify that in the performance,of the work for which this permit H sense,I shall employ pareore subject to workman's compensa- <br /> tion law.of California." <br /> The applican moat inquired immecdon.. Comdata drawing on erne side. <br /> Signed X oil for Ties: s.✓W/JA Gets: <br /> _ _ ____ ___—._FOR DEPARTKOAMA)SE ONLY___/_1. _,. ___.��F.-- _ <br /> Application Accepted IsY if,, Dab 6 -; �^� Ares ,�J�y <br /> Pit r Grout Inspection by G eta - .t Final Inspection by� Dst i$ <br /> Additional Comments: <br /> ❑ Stk 466-e191 ❑ Lodi MIS 3621 ❑ Manleo V3-7101 ❑Tracy 0354MS 'A <br /> Applicant� Return all copies to: Envlronmerdai Health Pemvt/Servieea 1601 E. Heedful Ave., P.O. eca , Stk., CA 95201 JOIN?, <br /> FEE AMOUNT DUE AMOUNT REMITTED I K RECEIVED BY DATE PERMD'NO. <br /> INS) CASH <br /> all 131low.leer o 7DLau <br /> all 420 <br />