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<br /> APPLICATION FOR,PERMIT
<br /> 4-yi�._G-, ,.,F yi
<br /> SAN J0AQUIN'rLOCAL,HEA1 TH DISTRICT
<br /> 1601 E—HAZELTON•AVE., STOCKTON, CA
<br /> 'Telephone (209) 466-6781f i
<br /> PERMIT EXPIRES.I,YEAR FROM .DATE ISSV99!,Ivi .'fit` '"w` , 1�,rdilijo .s
<br /> ��i�t,��^�t�sw�,"»��,��'+_i+�+'�c���?;',#�•13i.��::�,v�r�r1:,;,IGompiete in,Triplicate?,�::�,f 3{q Rtl�fiiS^�C f�i~:..��rtE4f€,+::tx-,n-�:e^•;�€tSIC', i=.
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereln`V abed This application is
<br /> mad6jr3,coinpliance'With`San:Joaquin.County,,Ord€nance Ng.-549;forse0mge or,No:x862;#or-well/pump:apoj4e:Rules;3nd,•Reguletoh6 of the Son;Joaquin
<br /> Local Health District ., r ,k ,' ' + t °I: I'M uf't;_" •io 17 t }S '.`C f epcd^ea 10 nai�'«aqF.� b^ai� g7)lq
<br /> �e vv� rG3l: (�1(> i4ft� � i'I �� ia` g � �f;4 §dd c J fi+�� ScC• '•P rt +S_S .0
<br /> Job Address ..T._ � _,,.,, ,. Ci LotdSize —,. - _ ,,. :PM.,__,. _
<br /> j �^ g�� �} �7t6 1 _ii S• 4 vim.- f
<br /> Address �i a t C��� �Wt�� µa•Phone-
<br /> Owner's Name _
<br /> F7F S License:No [-�5 5 r Phone
<br /> �__-/Contractors Name-- - _ -..-_ _
<br /> I STYPE OF;WELL/PUMP:; i NEW WELL ❑ ! WELL REPLACEMENT [Ii. DESTRUCTION ❑
<br /> 'SYSTEM'REPAIR ❑ OTHER ❑
<br /> - PUMP"INSTALLATION ❑ i-
<br /> f ! SEWER LINES- ('DISPOSAL FC-D.— PROP. LINE r
<br /> DISTANCE TO NEAREST SEPI IC TANK ,
<br /> l s
<br /> OT FOUNDATION AGRICULTURE WELL]
<br /> PITS/SUMP•S
<br /> I HER WELL
<br /> - INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS 9 s
<br /> T .. _ t
<br /> w
<br /> I-'---�0 Industrial -•r'-• ❑i0pen-Bottom ❑ Manteca,, Dia. of well-Excavation - - 4 ,Dia..of Well Casing
<br /> I I❑ Domestic/Private ❑:Gravel Pack I 10 Tracy, i ` Type of Casing Specifications _
<br /> l_ t "' be 4h of Grout Seal Type of Grout: h
<br /> ❑ Public i I ❑ Other El p; t 1 "
<br /> i---- C7-Irrigation--`••�---j-• �r -Approx, Depth - ©"Eastern G~ - Surface_Seal Installed by --
<br /> s iH P z State Work-Done—
<br /> Repair Work Done ❑ Type of;Pump
<br /> Well Destruction L3I'Well Diameter `Sealing Material (top 501 ,T r
<br /> _ i ! Below 501
<br /> ,-.Depth 'Filler Material '
<br /> -
<br /> 'TYPE OF SEPTIC WORK: NEW INSTALLATION Wi AIR/ADDITION ❑ `DESTRUCTION ❑ (No septic system permitted if public sewer is
<br /> a. '.._ . i.. available within'200"feet.). _ _
<br /> . REP
<br /> __. �•
<br /> 3Installation vi+ill serve: s Residence�-, Commercial Other I I
<br /> Number of living.unrts: Number of bedrooms
<br /> CFiaracterof soil to a depth of 3.feet: p = " 'iWater table depth
<br /> '' 1 : j Capacity —� 'No. Compartments,
<br /> SEPTIC TANK ` 4,:Type/Mfg_._ '
<br /> ;PLTi❑ t F , i g Method of disposal
<br /> PKG. TREATMENT ,
<br />�, t Distar�g to nearest. Well FouProperty Linendatior 7
<br /> of
<br /> LEACHING LINE j5_;No & Length of lines V& Total length/size I
<br /> c ' -r- d-ri r I' undati *"""`.. - -property tine
<br /> FILTER BED + ❑�iDistance to nearest ""Well } tT.
<br /> i l
<br /> i`• 1 Size' r Number,
<br /> SEEPAGE PITS I Depth' p
<br /> r� / l r z
<br /> _h l - Foundation Property Line
<br /> } i. '
<br /> ISUMPS ' # i RC]' Distance to nearest Well�� "
<br /> iDISPOSAL.PONDS._ `O
<br /> I hereby certify that I have prepared this application and that theiwork'will be done in accordance with San Joaquin county ordinances, state laws, and
<br /> i rules and:regulation's-of-the-San Joaquin-Local-Health-District, - - ,--u -- •----�^ " '{' l / i"
<br /> i Home owner or licensed,agent's signature certifies the following:;'I certify that in the performance of the work for which this permii is issued, I shall not
<br /> employ any person in•such-manner aarto.become subject-to workman's;compensation.laws•of.Cal'rfornia."Contractor's hiring or su�contractirig signature,
<br /> i certifies the following:'I certify thatin the performance of`the work for which this permit is issued,I shall employ,persons subject to workman's compensa-
<br /> i tion la - .,lifo nia.' r..� j -' -- ' __ . - ,`.' '. _.. . .,�F m w . .� 9
<br /> The;app cant, u all for quired in c ions. Complete drawing on reverse side. w-;m� T
<br /> �, :• ._
<br /> a 4r t Title ��� �� Date:
<br /> i Signed � ° - o � ,. f .. ONLY
<br /> r { .it { # - F
<br /> (p+ FOR ....DEPARTMENT-USE
<br /> 1 F Application Ac epted by '1 �' ` Date = `I n1111111
<br /> Area
<br /> Pit or Grout Inspection by Date _ Final Inspection by w Date
<br /> i • ,�-y-�-�;-- � its ��14- , I i ' ..Y. .., ,.,..... "_ I
<br /> I
<br /> Additional,Comments:
<br /> ❑ Stk -466 6781 -1 O Lodi #. C3-Manteca .823-7104_ !:_❑Tracy -835-8385
<br /> - Applicant Return ell copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2W%9 Stk.; CA 95201 ;
<br /> ,ica t• tun _ - -. _- f - -v
<br /> 4 V-FEE ~-iAMOUNT DUE AMOUNT REMITTED" I ~CASH i RECIZWEq 8Y# ' DATE 'N
<br /> PERMITO,
<br /> INFO
<br /> i+ EH 13.24€REV-tb1831 �l i 1 ,- -
<br /> EH 14-28 ,F.-
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