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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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 described.TMs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address T : /1t 1 'S �i% C!`2PA L �!!%L L�-(i t(r City— Lot Size PM <br /> Owner's Name ' "-T` PnI TFA N4 Address 12CAI l! !1'i2c I Phone cy-Af— <br /> Contractor:. 1r cc✓AIEc'Y Address n C 2 (•1 v(�.Q !- 't- <br /> TYPE <br /> r License No.�A t�h /!- ci Phone ' 1 - - % - <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE Ain rr <br /> FOUNDATION _ .1n r AGRICULTURE WELL OTHER WELL 3°� r PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `! (g! Dia. of Well Casing tj A. <br /> ❑ Domestic/Private ❑ Gravel Pack J@ Tracy Type of Casing j I0f1i7g - nOt— Specifications <br /> fl Public 6L01her-yA n(E 71 Delta Depth of Grout Seal r9 t Type of Grout n_l <br /> I I Irrigation- Le_Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done D Type of Pump H.P. State Work Done _ <br /> Well Destruchon 1--] Well Damxrer <br /> me.... �! <br /> E > g, � 2L� 'Z aANK OF AMERICA <br /> �� w�aF�y� e,eo Evro,a yssa - paver is <br /> SEMCO 807431 W. HATCH RD. (209)5249653- 1 <br /> MODESTO,CALI FOR NiA 95351' - <br /> •� ` ; grr����^^�^ p� ,g' DOLLARS "1 <br /> PAY <br /> 67C7YfVlJ 4 -0-P&S tl <br /> TO THE ORDER OF DATE CHECK NO. AMOUNT 1 <br /> SEMCCI J <br /> I <br /> e laws, and <br /> s , 1 shall not <br /> I ,> g signature <br /> ' i compensa- <br /> The applicant ro/u////st''call for all reauire inspections`Complete drawing on reverse side. �G <br /> Signed X /r"�fq•K -r/ L 1 a.J,7 Title: �^/+�--4.i� Date: r'/— ns' ` 2 <br /> f�/ FOR EPARTMENT USE ONLY <br /> Application Accepted by 47 � Date Area !2 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8V DATE PERMIT <br /> EN <br /> 1 <br /> . EH 14-211REV.r;xS) —._ 5�. (J <br /> EH 1324 �{rt Y <br />