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SEP 19 1988 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F.NV(RONMENTAL HEALTH <br /> 1601 E. HAZELT ON AVE., STOCKTON, CA <br /> PERMIT/SERVICES <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 11,YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desaribed.'This'application is <br /> made`in c6mpltahce:with Sen Joaquin County Ordinance No.549 for sewage or No.1862.for well/pump and the Rulwaqtt Regyt,tions of the San Jt>aaquin <br /> Local Health District, <br /> F <br /> g([3 !'HJ �� city ..___ Lot Size PSA,-,•---- <br /> Job Address �_ <br /> � a <br /> 3$f�frktietit�,�- 4 2�9 <br /> Owner's Name ss Phone <br /> 71 <br /> Cgntractgr, Address to ✓& ".14 EO�nstf N6. o2 7l Phone <br /> TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR # OTHER ❑ <br /> DISTANCE_T0—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 Well Excavation Dia, of Well Casing . <br /> .Domestic/Private GI Gravel Pack ❑ Tracy Type of Casing Specifications <br /> a f 1 IPublic n, Other (1 Delta Depth of Grout � Tyge of Grou} _ <br /> L k Il+rigatie�+-� - w Apca�a, Dytb_� _//-lidstern..,.. . SutteesSsa6,lnsiahad by <br /> Re au Work Done E! Type of Pump 4M4 H P — State Work Done <br /> WAIT Destruction <br /> Q Well Diameter Seating Material ftpp 50'1 <br /> Fi11of AAateriaf.lBebw-50 1 .'_.... <br /> TYPE OF SE TICIWOI#K: NEW INSTALLATION I I REPAIR(ADDITION I I DESTRUCTION 1 1:(No septib system permitted i1 public sewer is <br /> ;. m . �_..._a.avai►abte•vrorHtrh-26�feet�... ., .�� .__,.,_ . .,.:, <br /> _ .: _..... _ . mercial Other <br /> Installatwn will serve: <br /> Residence— Com, Other <br /> Number of_livin units, Number of bedrooms <br /> s - <br /> �Chara�rroif saif108-depitt-o"••feev - - �ltlfater tdbfe d�pth~�� � <br /> SE TIC TANK ❑ Ty e/Mf Capacity No ComPartments� , <br /> PKP. TREATMENT PLT.❑ Method of Disposal <br /> f9tstance to nearest:' Well.. „ _,.. Paungatlon. Pr7tpirry`tlrre,. <br /> I <br /> CHING lytNE ❑ No Length of litres Total length/size - <br /> T�-��;._. .Watt Foundation <br /> SEEPAGE PITS 1 I; Depth ' Size Number I <br /> StfNFPS tel, Distance to'tlearest: Wgry__. ._._ otrndat►orr _ Propertytirte _` <br /> DISPOSAL PONbS ❑� 1 <br /> 1e cert' that I Have prepaled this aprplication and that the work will be done in accordance with San Joaquin county ordinances, state lavk, and <br /> � by <br /> _gulps acrd cegulati®ns o t!eSan-eJoaquin 1, -kfealth-D4 quct. <br /> Holme owner:or liaenseid a nt's i na ure cjertifies the following: 1 certify that:in the performance of the work for which this'permit is issued,I sf all not <br /> employ ar►y perso�in.such-Mann4r a s-to.befiorsretsublect to workman s-aoFnpeagatron..laws-of C.aWfarnia Gsntraatoz s hHing gr au j eentTaetirag aTnetti{e <br /> ceRifies;the following:91 certify that in the performance of the work far which this permit is issued,I ahall employ persons subjeFt to workman's compensii- <br /> ._._;.._tiop.la+n�-af-•Oalifornia.4_ .. ...._ '___ -.....! _. _ _. __ ,. _ _, . . _. ._ .,_ _..a_�.a._ <br /> Thp applican udt call sII-recurred inspections Complete drawing on reverse side I <br /> _. _ ...._ _ <br /> Signed TitlDate. <br /> r1A�• <br /> FOR;DEPARTIAENT USF NLY <br /> f <br /> Application Accepted by Dt Area <br /> Pit�or Grout Inspectionjby + Date Final Inspectioniby MIW Date <br /> Additional Comments: <br /> A�licant Return all Copre to: Onvir6nmental Health Perrnit/Services 1601 EHazalton Ave P.OBox 2!103" StklCA 95261 i i <br /> 1 7fKlOt)lV1 T1UE 11iir7isf liLKllitTt) CASH <br /> µ IV€D BY. {DATA y jP'ERMIT NO. <br /> +.EH1324IaEV. <br /> EH 14-2s <br /> �i85i <br /> �:/ <br />