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APPLICATION, <br /> PERMIT <br /> SAN JOAQUIU,LOCAL-,HE4LTH DISTRICT <br /> i. 1601 E.-HAZE'7W <br /> T0, AVE., STOCKTON, CA <br /> 'Telephone <br /> Telephone <br /> � , (20 9) 466-6781_ <br /> 11'0Y.I ,1;7� -5-,v Ff-4_!std <br /> IrY !'�Y '­, 9 F3 N r" 4"10E Di I ?'3:71;.! QPERMIT EXPIREi-1YEAR FROWDATE.ISSUED <br /> IfV-Q )et9C010 J' <br /> qa <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereon'd6icrilb4d'."rNs-a0plication is <br /> made in compliance:With;San:Jpaquin-,County,,f)rdinance'No.^W for.seWage or.No:,;18§2-f or,well/puinpand the;Rulesand Regulations of the San Joaquin <br /> Local Health District--., <br /> 10 <br /> Job Address City 2r. A0,01ot-Size, PM <br /> Address <br /> Owner's Name Phone <br /> -Contractof s Name <br /> "i759ns e No. <br /> Phone <br /> TYPE OF,WELL/PUMP: <br /> NEW WELL, � WELL REPLACEMENT El DESTRUCTION C1 <br /> PUMP.:INSTALLATr)O B`� SYSTEM REPAIR -EJ <br /> N OTHER <br /> 7Z <br /> DISTANCE To NEAREST: SEPTIC TANK MOW SEWER LINES N410e- DISPOSAL FLD. -6 PROP. 'LINE"l-�--erl- <br /> FOUNDATION &� AGRICULTURE WELL,&_1,9_— OTHER WEL <br /> PITS/SUMPS <br /> INTENDED USE Typi OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial P5'0 en.Bottom 11 Manteca- Dia. of;;�,Il E.cavation <br /> Dia of Well Casing IF" <br /> &-yo-mestic/Private [].Gravel Pack El Tracy Type of Casing Specifications <br /> D Public ❑"othe'r .11 Delta Depth of Grout'St./.I <br /> Type of Grout del­*421 <br /> 0 Irrigation IW96p. rox Depth -_E] Eastern 'Surface Seal Installed by' Ile i-. 4L <br /> _4.�pair Work Done El Type of;Pump H.P. .14 — State Work Done <br /> :Well.'Dest'ruction D Well Diameter Sealing ma-Cenirj itop 50'. <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONM !REPAIR/ADDITION [I DESTRUCTION El (No septic:system permitted if public sewer is <br /> available within 200 feet.). <br /> Installation will serve: Residence CommerciO_ Other <br /> Number of living units:' Pumber of bedrooms <br /> Character of soil to a depth of 1 ­ <br /> feeti �` Water table depth <br /> .SEPTIC TANK 0 Type/Mfg Capacity— 'No. Compartments <br /> Method Disposal' <br /> PKG:. TREATMENT PLT: El of <br /> Distance--to-nearest: Well Foundation Property Line, <br /> LEACHING LINE I,"' El No. 6 Length of,lines <br /> Total length/size <br /> FILTER BED 0-Distance to nearest: ;Well P -Foundation Property Line <br /> SEEPAGE PITS 0 Depth 1 Size Number <br /> Nu rnber <br /> SUMPS C I Distance to nearest i-' -Well, Foundation <br /> Property Line, <br /> DISPOSAL_PONDS 17 <br /> I hereby certify that I have prepared this application and that the work.will be done in accordance with-San Joaquin county ordinances, state laws, and <br /> rule <br /> s and'regulations.of the San Joaquin Local Health District. 'Ar <br /> Home owner or ficen' sed:agent's signature certifies the following:;'I certify that in the performairi'c'e-of the work for which this p I ermit is.issued, I she.11 not <br /> y-a <br /> amp!ony-person in-such-manner as-tq-become-subject%to-workman.scompensation.lows-bf.Cali'f'orn.ia."-Contractorls.biri.ng.or-sub-contracting signature.-- <br /> certifies the following:"I-cerff-y that in tAe performance of the work for which this permit is issued, I shall employ,persons subject to workman's compensa- <br /> tion4aws of <br /> The:appticant must call for all required insctiorts. Complete drawing�on eveerse side. <br /> P-e <br /> Title: <br /> Date; <br /> FOR DEPARTMENT ONLY <br /> T L <br /> App ication Accepted by., <br /> Date An <br /> a Final Inspec on Date <br /> ate Pit or Grout Inispection by <br /> Additional Comments: i i -4- <br /> 11 Stk 466-6761 E3 Lodi- 369-3621 El Manteca .823-7104 1:1 Tracy 835-6385 . <br /> -Applicant- Return all copies to: Environmental Health PerrRit/Servicei 1601 E. Hazelton Ave., P.O. Box 2009,'Stk. CA 9524I <br /> FEE4 <br /> AMWNT DUE AMOUNT REMITTED QK JV RECOVED BY DAfE <br /> CA_9H <br /> + <br /> EH 14-28, <br /> EH 13-24 IREV.10/00) q�oo <br />