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APPLICATION FOR PERMIT <br /> 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 16011 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXF IRES�AR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> rnado in <br /> it hereby meds to the San Joaquin Local Health District for a permit to construct and,/or <br /> meds H Health <br /> Dance with San Joaquin County ordinance No. 5is fur sewage or N <br /> Local Health District, Install the work herein described. This application is <br /> O. 1862 for waN/gum s and <br /> Regulations of the San J <br /> r A and the Rule3zp oaouin <br /> 2 <br /> Jab Address <br /> f City tat Sire <br /> Owner's !Name -S�i/"G< �//� Ply <br /> Address <br /> Con �r/��✓it�l� 363 O,�r,�d �;ee.�d� -��- ........................ <br /> F Address ��cr! G+.Q yS�f/z r7 <br /> TYPE of WELL/PUMP: License No. <br /> NEW WELL (] wELL REPLACEMENT v —�---Phone <br /> PUMP INSTALLATION r�` DESTRUCTION L:i <br /> DISTANCE TD NEAREST: SEPTIC TANK -,r SYSTEM REPAIR ❑ <br /> �� EWER LINES OTHERo I' <br /> FOUNDATION !hr'f DISPOSAL FLD„__ PROP. LINE <br /> INTENDED USE Aa;RICULTURE WELL _` <br /> f TYPE OF WELL - �—-"' 0•�HER WELL <br /> ❑ Industrial . LL PROS AREA ~^�—�����- PITS/SUMPS <br /> 4,open Bottom CONSTAUCTION SPECIFICATIONS ~� <br /> r� Domestic lPNvate (J Manteca Dia. of Well Excaval •`i, ,` <br /> L7 Gravel Pack <br /> I'I Public f:� Orhar fl Tracy TYpa of Ga>fih� ,r a Dia. of Well Caging �GGF <br /> i r Irrigation Zo' I 1 Delta Depth at Grout Seel.ds. a SpeCiftations <br /> Approx, Depth I I EastOrn <br /> Repair Work Done Surface Soul installed by /Q Type Of Grout <br /> L] TYPe of Pump <br /> Wall Destruction 6 H•P. <br /> Ol 5"Gil s l�:•� ❑ Well Diameter State Work Done,�Sa%C1<56 - IN <br /> Depth Zc ' Scaling Material (tap 501 n <br /> TYPE of SEPTIC WORK: ~�'�- Filler Material {Below 50') <br /> NEW INSTALLATION I 1 Ii EI'AIR:ADDITtt7N <br /> { <br /> Installation will serve; Residence permitted if public sewer is <br /> Commercial f DESTRUCTION I 1 INo septic system Other available within 200 feet.! <br /> IVurttbef Of living units: Numbor of bedroornt <br /> Character of soil to a depth of 3 feet: �_�,- - <br /> SEPTIC TANK <br /> ❑ TYPe!MfB ~��~—~• Water <br /> PKG, TREATMENT PLT, C) table depth <br /> Capacity�- No. <br /> COrttpantrrtentS <br /> Distance ton rest; <br /> � Wel! Foundation Method Of DigPoaal <br /> LEACHING U —��` Property Line_may <br /> NE n -_ <br /> No. & Length of tines <br /> FILTEfl SED L3Distance to nearest: Total lo <br /> Well � r+gth/size <br /> Foundation_,�� <br /> SEEPAGE PITS Pro Darty Line <br /> SUMPS I I Depth _.•�� .. <br /> Size <br /> Ll Distance to nearest: Well _ — Number <br /> DISPOSAL PONDS L-1 Faundarmn- �"`~ - <br /> 1 hereby certify that I have Property Una <br /> ve prepared this applicaY . <br /> rules and ra ulatione f ion and that t <br /> $ o the San JOII Local H work will I,te done in accordance <br /> Home owner Or licensed agent's signature ce sahib Drl:triCT. ce with San.loaquin count ordi <br /> employ an rtitiBs the faftowing; "f certify that in the performance Of Y nancea• state taws, and <br /> y person in such manrtar as to become subject t0 Workmen's Compensation taws of California.,, <br /> certifies the following; "1 carnty that in inswok for which this } <br /> tion laws of California.' Performance of the work for whish tltis Contractor s hiring permit is rasued' I shall not <br /> The <br /> a parrrrft is issued, I shall contracting signature <br /> pWicant must cal! to <br /> all reovirad inspections. Com employ persons subject to workmon•s Com <br /> Plata drawl �n <br /> Signed X '�/� � /�/i�.�/yJ f. rti8 On reverse side. <br /> Title: -,4r. <br /> Data: <br /> Application Accepted by F EP NT USE ONLY <br /> ,1 <br /> a <br /> pit or Grout Inspection by DZE�a <br /> Date Ar a <br /> Additions! Comments: Fina! Inspection <br /> ❑ Stk 486-6781 ❑ Lodi 369-3621 Date <br /> Applicant • fleturn all espies to: Environmental HaelthaPeem t/ca M3-7104 <br /> ❑ Trac <br /> rtes 16tH y x-6385 { <br /> E. Hazelton Ave., P,O, Box 2009, Stk. <br /> FEE CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK s <br />'r*73.74 ERE;V,lin» CASH RECEIVED aY <br />'M 14.78 DATE . <br /> PERMrT'N0. ' <br /> /ZZ 7a /3� p <br />