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1 <br /> 0i I <br /> APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k ms . `13' *. 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209).466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED <br /> (Complete in.Triplicate} t-j -7j, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describe This a plication is <br /> made:in compliance with San Joaquin County Ordinance No:.549 forseWage or No.,1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.,..."!, t! <br /> Job Address il/S ad —.City .1 Tbr-6til;i�-Lot Size PM <br /> Z-e <br /> Owner's Name OL.Att -42ACC za, Address S O Phone <br /> Contractor's Name 4ZAjteA4.JJ PeA1a!s!0 License No. �6rUl_ Phone V6V__?k1Tr <br /> JTYPE-­OF WELL/PUMP: NEW WELL ;K WELL REPLACEMENT D DESTRUCTION El <br /> PUMP INSTALLATION :SYSTEM R EPAI R 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC7ANK SEWER LINES i DISPOSAL FLD.1-44 PROP. LINES r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial L1 Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing _4�_ <br /> ?eDomestic/Private 19 Gravel Pack 0 Tracy- Type of Casing .00 4V Specifications '.Til-4C#4O <br /> El Public 1-1 Oth r 11 Delta :Depth of Grout Sea] Type of Grout t'9U441AW <br /> D Irrigation iazpprox. Depth. 0 Eastern -gurface Sea[ Installed by <br /> Repair Work Done 0 Typii_6f,Puml3.r.,, nlu A H.P._J;�2_ State Work Done <br /> Well Destruction D W611 Diameter ',Sealing Material (top 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E:1 REPAIR/ADDITION El DESTRUCTION C1 (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence— Commercial Other <br /> Number of living nits: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I—Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENTiPLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> A : <br /> LEACHING LINE 11 No. & Length of lines f Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Prop" Line <br /> SEEPAGE PITS C1 'Depth -Size Number <br /> SUMPS UM M Distance-to nearest: Well Foundation- i Property Line <br /> DISPOSAL PONDS1 LJ <br /> I hereby certify that I hal3 prepared this applic6ion and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Xpaquin Local Health District. <br /> Home owner or licensed agent's signature certifi.ei­.the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> erhploy any person in-such manner as to becomesubjet;t'-fo workman's compensation laws of California."Contractor's hiring or sub-contrecting signature <br /> certifies the following: "I certify that in 64 pl;rf-rmance�of'the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call all requ d ins c ns. omplete drawing on reverse <br /> Signed71-2,? <br /> Title: _-Daie:_ <br /> R DEPARTMETENTIUSE <br /> 9[11LY <br /> �41- <br /> AZ-4< <br /> Application Accepted by Date Area <br /> 67 <br /> Date <br /> L13 <br /> Pit or Grout Inspection by Date �_ Final Inspection 6 Date <br /> � <br /> b <br /> is <br /> Additional Comments: I I <br /> 0 Stk 4-66-6781 0 Lodi 369-3621 E3 Ma6teca 823-7104 C Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO. <br /> FEEi ' AMOUNT DUE AMOUNT REMITTED CASH K RECEIVED By DATE PERMIT`NO. <br /> A—C) 3 <br /> EH 3-24 IREV.10/83) 0 C�h <br /> EM IW26 r F&— <br />