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<br /> APPLICATION FOR PERMIT PAYMENT
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<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED +
<br /> L► L,;
<br /> HAZEL T ON AVE., STOCKTON, CA
<br /> Telephono 12091 466.6781 �� l•3 IITT
<br /> �. �R
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSII-V1V1R0NMRgTAL HEALTH "
<br /> (Complete in Triplicate, PrRMfT�SER`✓ICES di.
<br /> ENVIROMENTAL HL;11F1I Ns
<br /> Application is here�I M�r,�ER r-1p.,9,nn Lrn 1 Hnalth Oistlicr for a permit to construct and'or stall the work harem A 'r. 'ions c.!he SanCloraqurn
<br /> made in compliancee with San�Joaquin Cotwly or,S>r,N,4f 1v`\�QJI 4 @RLtWE? �19r�J r rt� rid the Rulegand ��
<br /> Local Health District. ENViRONti1ENTAL HEALTH DIVISION, L JL••vl cS ,''.
<br /> - r� �y_.x . PEI ,M Lot Size_Y-���=— PM---
<br /> Job Address �� �lf�-_ y - O
<br /> _�ir .P,1 r �= Address /_�"./�'`' _P z4' i^_r-`-'Q hors. �D-
<br /> _ /a i
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<br /> Owner's Name '77 r/ �j ,; vt �j r-
<br /> ,yCtft y/►�lC'/? `n t i b�`Y 7/ L�crt�y rG
<br /> J Ad'Jrr� c^7 1 rise No.
<br /> Contractor �'Q Q
<br /> -�l 777
<br /> v,
<br /> TYPE OF WELL/PUMP: NEW vJELI. � WE L REP ,,CEMENT U DESTRUCTION l I
<br /> Maw, \n�5�STEM REPAIR ❑ OTHER Cl g'
<br /> PUMP INSTALI-ATION I �g� 12—q:.
<br /> .II`'POSAL Fl.D. _ �- F'RUP. LINE _
<br /> SEWER LIVES _L1�L L rf�t
<br /> DISTANCE TO NEAREST: SEPTIC TANK _L r(� ,�
<br /> FOUNDATION A,RICULTURE WELL;OW OTHER WELL 1 U_LZ— PITS/SUMPS
<br /> r x
<br /> INTENDED USE ATYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_
<br /> _ - /f —_— Dia. of Well Casing (IxVJ
<br /> 11 Industrial 0 Open Bottrn, I Manh':a Dia. 01 Well Excavation/' _ ,rauo
<br /> Speci[ ns
<br /> Cl Domestic./Private ,RI Gravel Pack lel 1iacy Type of Casing__L7_G_-- -- ---- ,
<br /> f'1 Public
<br /> (1 Other I I Defla Depth of Grout Seal .___. S f Type of Grout
<br /> 1 1 Irr'gatio yep Approx. n^nth I t Eastern Surface Seal Installed by_
<br /> Re ar a �6roe! IJ Type of Pump N.P.— _— State Work Done— --
<br /> r
<br /> Sealing Material Itop 50'i —
<br /> Well Destruction ❑ Well Diameter fl
<br /> Depth r Filler Material(Below 60'1
<br /> TYPE OF SEPTIC WORK: NEW INSTALL,\I WN I ! Ill PAIWADDITION I I DESTRUCTION I ! (No septic system
<br /> m emitted if public sewer is
<br /> Installation will serve: Residence_— Comrnnrdal —. Other
<br /> Number of living units: _^— Number of bedrooms— _—_ (\ s
<br /> Water table depth-----
<br /> Character of soil to a depth of 3 feet •
<br /> _..- Capacity__. -----_ -- No.Compartments _------ --
<br /> SEPTIC TANK Cl Type/Mfg n
<br /> PKG. TREATMENT PLT. FI Msthod of Disposal --- {1-
<br /> Distance to nearest: Wall Foundation_.—._—_.— Property line — t1
<br /> --___
<br /> LEACHING LINE 1_1 No. R Length of lines -- Total length/size--
<br /> FILTER
<br /> ength/sizeFILTER BED 11 Distance to ne;vr•st Well_ __--_-. Foundation -. Property Line
<br /> SEEPAGE PITS I I Depth __ `ire —�� - _ Numbur_ --
<br /> SUMPS I 1 Distance to onarom Well_ ._. Foundation Property Line
<br /> DISPOSAL PONDS 11
<br /> I hereby certify that I have prepared this application ar,d that the work will be done in accordance with San Joaquin county ordinances,state laws,and rC qY
<br /> rules sad regulations of the Sen.lonquu, 1,)r Al [inch r nd,rrirt
<br /> Home owner or licensed agent's signature ceruhes thn followingperformance
<br /> : "I certify that in the of the work lot which this permit is issued,(shaft not •
<br /> empty any person in such manner as to taverna subject to workman's compensation laws of California."r ontractoes hirir,d or sub-contracting signature
<br /> certifies the following:"I certify that in the performance of the work for which this psrmFt Is i:aued,1 shall empty persons subject to workman's toet0ensa• _
<br /> tion lawn of California." 1
<br /> The appi t must tall f r all requirn mfipochr nr:. compinto drawing on reverse Ide.
<br /> nn AA
<br /> Signed X ;j�1.l�,,l _ Tine: �roleelQr-t`.GL_ Date: �
<br /> FOR DEPARTMENT USE ONLY DateAreaApplication Accepted by ,11(r�- `.• ..I----------
<br /> rte/
<br /> x!)11 Date_.!/_'�'d= Final Inspection by Date �Y
<br /> Pit or Grout Inspection by — -
<br /> Additionel Comments: _.— -- - —~
<br /> 0 Stk 480-6781 0 Lodi 3G9 1671 [i Manrece 8237104 O Tracy 835-8396
<br /> Applicant Returr all copies to: Environmental Health Permit/Services 1001 E. Hazelton Ave., P.O. Box 7000, Stk., CA 95201
<br /> FEE AMOUNT DUE AIA REMITTED CASH
<br /> RE�EI\rf0 nV DATE s PIRtMIT NO.
<br /> INFO --- --- V k7
<br /> �j�, �r ham`
<br /> tM a 24 IeSV,,, n 34 7f"1 --— -•_ -__--
<br /> FN1426
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