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APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ;t j <br /> Teiepllorte (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM ©ATE ISSUED <br /> i (Complete in Triplicate) <br /> Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or Install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rulas and Regulations of the San Joaquin <br /> F <br /> Local Health District. , <br /> ,, i <br /> Job Address City �� A[ //t SizeC PM <br /> ID <br /> Owner's Name + ddress !! RnX ? f.F� 1.1P��BtiT 14 klone oj� <br /> f t Centractnr �T 1 f 1 t + D Addies License No. ,9 2 h _ 1/6 r <br /> TYPE OF WELL/PUMP: NEW WELL F—✓` WELL REPLACEMENT <br /> DESTRUCTION M-- <br /> TYPE <br /> INSTALLATION L4� SYSTEM REPAIR Ci OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKh SEWER'LINES _ /f/1 pISPOSAL FiD. PROP. LINE <br /> FOUNDATION 5J2 AGRICULTURE WELL JA24Q__+OTHER WELL_ ?n PITS/SUMPS 1C'Q /4- <br /> INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS !� <br /> [1 Industrial 11 Open Bottom f ' Q Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> f]i.�omesticlPriyale p� Pavel Pack Trl�py Type of Casing �� ,ter Specifications 1 {I <br /> I'l Public fl Other fi Delta Depth of Grout Seal -.. [Z i ype of out i?l?J <br /> iI <br /> I I InivationApprox. Depth l i astern Surlace Seal installed by pp , <br /> Repair Work Done ?f Type of Pump H.P. —� State Worjl- one_ \J <br /> Well Destruction +&ir Wall Diameter - Syaling Material (top 501 I� <br /> Depth 7 Biller Malarial (Below 501 _11:1k _ 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 i REPAIR/ADDITION i 1 DESTRUCTION I I Wo septic system permitted if public sewer is i <br /> available within 200 feet.I <br /> Installation will serve: Residence^ Commercial_ Otherj <br /> Number of livingunits: Number of bedrooms <br /> Character of soto a depth of 3 feet: Water table depth3 <br /> SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments <br /> PKG. TREATMENT PLT.n Method of Disposal <br /> Distance to nearest:' Well Foundation Property Line <br /> LEACHING LINE ❑ No. fA length of lines Total length/size <br /> 1, <br /> FILTER BED 177 Distance to ilearast: Well Foundation Property Line !! <br /> SEEPAGE PITS I I Depth Size '— Number <br /> SUMPS Li Distant$ to nearest:,; Well Foundation Property Line <br /> DISPOSAL PONDS n <br /> i <br /> ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> P rules and regulations of the San Joaquin Local Health Di$tricl. I <br /> ' Home owner or sac" 'a signature certilies the following: "I certify that In the perforn)once of the work for which this permit Is issued, I shall not'. <br /> employ any on i such man r as to become subject to 6 tan's compensation Iowa of California." Contractor's hking or sub-contracting signature ? <br /> certifies the f Ilowing:"I carol th in the perfor a c oft wprk to hich this permit is issued, I shall employ persons subject to workman's compensa-i I 1 <br /> lion laws of California." <br /> The applica t.must call o /equlred she fete to ing'on rev idol / <br /> Signed X1 {''/1 t + ilia: Data: `t2 �! ; <br /> EPARTMENIT USE ONLY <br /> Application Acc6 <br /> apted by � ��� LN �' �` Date �� �� . . Area C� 1 <br /> Pit or Grout Inspection by D Final Inspection by Data�W �I <br /> Additional Comments: <br /> Ll Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies t Env pnmeNai FFl�aPermit Servic 160 E. on vgg��r� P-0. Bort 2009, Stk., CA 95,201 <br />, • �J:rc„�.a1t,r..�J cid .,.>� w• �a.;�v,,.►..]•�'15. <br /> 1CKS <br /> F O A OUNT QUE' AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT'NO. <br /> � tr <br /> �-EK 13.24 IREV,111,61 <br /> EH 1/-ss <br /> o i <br /> k <br />