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A4% -R Zy 15 dry°5 y <br /> r 11 <br /> APPLICATION FOR PERMIT /� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 6e4cchnrcck <br /> � - .----•��"�1601 E. HAZELTON AVE., STOCKTON, CA �jo-�� S C� <br /> Telephone (209) 466 6781 lVa , +R7 � <br /> ��- PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDZ�c. aLysri - � <br /> � _.. (Complete in Triplicate) T1k1_f rr►,jd <br /> plic 'oj2 is hereby made to the San Joanpermit Local Health District for to construct and/or install the work herein described. This application is <br /> ma compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of he San Joaquin <br /> Local Healii District. 1 <br /> .s4l� Wz, (t��polea) �: L�7� zfor7�� <br /> �, x (nu City Lot size �2. f3 PM <br /> ,address � n 1 1 <br /> E! S i�wJ�S CPNST�- Address 13`41 l� . r�ab��'t�ocJ �r i Vfe Phone <br /> Owne Name . CA <br /> `��b��� Phone_3�I-Ilo`r'O <br /> ftntra or Q l �1 �'` Address LV License No.__ - - <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION P( <br /> PUMP INSTALLATION ❑ / SYSTEM REPAf13 .0* OTHER��e_s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` OISPgSAL-FLD. " PROP. LINE - <br /> FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL _ PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ��• ti <br /> f nc -S Dia. of Well Casin <br /> a Industrial El Open Bottom Ll Manteca Dia. of Well Excavation 9 <br /> Domestic/Private El Gravel Pack ❑ Tracy Type of Casing fUOSpecifications j_M^_un,4 <br /> f'1 Public Other F1Delta Depth of Grout Seal !! Type of Grout, <br /> I f Irrigation &"1C+Approx. Depth l 1 Eastern Surface Seal lnstalled by = o <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter -lnc Sealirig Material (top 50') <br /> SA5.j,,f2ce 2n+es4. Depth Filler Material IBefow 50'4 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I'HNo sepl'c Wt+em permitted if public sewer is <br /> -7 1ivailablevoithin 200 fe-et.) <br /> Installation will serve: Residence_ •Commercial_ Other ` r <br /> !� r <br /> Number of living units Number of bedrooms r "� <br /> Character of soil to a dffo"w feet: Wat tEe depth <br /> SEPTIC TANK '0 Typ fg Capacity�..�__._ .*oto. Ir <br /> PKG. TREATMENT PST. C] f, P t Meth isposal <br /> Dif anee to nearest: Welt Fourdatio n Property Line A <br /> LEACHINtLINE ❑ No. & Length of hn Total length/size <br /> FILTER SED ,. ❑ Diyl6ncp t4 i ll� Foundation Property Line- <br /> y . <br /> Aly <br /> xV ! a <br /> SUMP k IS u n P ►-�.'•. f �.` <br /> " ��-DISPDSXkL RO1rYp5-- +t <br /> I hereby certify that V a've pre 1a the�".w6rk will be dor)._ ith quip'county <br /> rules and regulations of the San JoaW-tEarwing: <br /> trict. ` � ' ? ' <br /> Home owner'or9ic�nsed'agent's signatur I y th a pe or h ' u$d,Vhatl not <br /> uemploy any.perAa m such manner as to become+'ribject to workman S`q'upensaiion [avis' ars ' ontrgctiAg.signature <br /> certifies the following:"I certify that int performance of the wor which this permit is iks d, !' etii Work n's coratpensa- <br /> aie �. # <br /> tion laws of California." <br /> The applicant my uired inspections. Complete drawing on reverse side. 'tr:. <br /> y Signe Title: rb cc fG•. it <br /> FO DEPARTMENT-USE ONLY <br /> tz F plication AccaVed�by Date <br /> t., -UAW, <br /> r <br /> J <br /> rout Inspection by Date �F,naf inspect by <br /> dditibna;-Comments: <br /> '- Stk 81 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy, 835 6385 " <br /> r y <br /> n turn all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20095 Stk„ CA 95201 L •# <br /> tFEE <br /> ! INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE )?ERMtr,.NO <br /> I i <br /> I <br /> I <br />