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yi <br /> APPLICATION FOR PERMIT <br /> .4 1 , <br /> SAN JOAQ_UIN LOCAL HE'ALTH DISTRICT <br /> 1601 E. HAZELT ON AVE.f:STOCKTON, CA <br /> —Teleplhone (209) 466-6781 <br /> "i"'n ­'If n- .� .;, h- � ­ ... . . I., .,aPERMIT EXPIRE 11 YEAR FROM DATE.ISSUED to _nt thlo <br /> .,-t!-,_q9mp1ete-inrTrip licate);!t,),o t, <br /> r4 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heiein described.Thisapplication is <br /> made in compliance with San Joaquin, ounty Ordinance No;-549 for towagepNo. 1862 for well/pump ancl:tha Rules and Reg6lations of the San Joaquin <br /> Local-Health District. <br /> fTlslria'. 100Z ,j­ '10 -."T'dZyp <br /> -5q na �,7-1 C��' .. " b- !'Ll 4� , <br /> Job Address City 11LVL1 -Lot Si_- PM <br /> f <br /> ?rdZ-15 co . Address �5 1-7 <br /> Owner's Name Phone <br /> t i't er <br /> Gontractor 1 0 . Address i3oyjZ��LLi<o License'No. "LIS Pho ne(I 10 6LIS— <br /> TYPE OF WELL/PUMP: NEW WELL M - <br /> 140rJELb ArX471,Pj12- <br /> _WCEMENT El DESTRUCTION 0 <br /> PUMP INSTALLATION 11n SYSTEM REPAIR El OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t i DISPOSAL FLD._ PROP. LINE <br /> 11 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT19,NS <br /> Ll Industrial 0 Open Bottom 1-1 Manteca Dia. of Well Excavation— 56 Dia..of Well Casing <br /> 1-1 Domestic/Private Gravel Packcy Type of Casing r <br /> V<_ Specifications <br /> Ll Public 0 Other El Delta Depth of Grout Seal 57 f pe 0 Grout <br /> Ir a ti '�Npprox. Depth Ll Eastern Surface Sea[ Installed by <br /> air Nor k <br /> .pair ork DO"* 0 Type of Pump H.P. State Work Done <br /> Well Destruction ', C1 Well Diameter Sealing Material /top 50') <br /> Depth 1 Filler Material (Below 501 \A <br /> TYPE OF SEP WORK: NEW INSTALLATION C1 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> Z available within 200 feet.) (IQ <br /> Lmiristallation will serve: R Commercial Other <br /> ErT <br /> ,F umber <br /> 1.4 <br /> of living units: Nu o bedrooms <br /> h <br /> r of soil to a depth of 3 feet;__i Water table depth <br /> TIC TANK 0 Type/Mf.g Capacity. No., Compartments <br /> TREATMENT PLT_ 0' F Method of Disposal <br /> Distance to nearest: Well riclation, Property Line <br /> HING LINE LI No. & Lengthoflines tal lengthisize. <br /> ER BED F-1 Distance to nearest: Well Foundation erty Line <br /> 8 Z PAGE PITS El Depth _r''Size Number <br /> PS" 0 Distance oto nearest: ;,Well <br /> Foundation- Property Line <br /> 0 ALPONDS <br /> I hereby Li <br /> that I have prepared thi7 application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I . I 'r, - <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> Gn certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensi- <br /> tion.laws of California." <br /> The applican <br /> must�?c for all re wired inspec'o s. C plate rowing on reverse side. <br /> O,OV <br /> Signed X LQAQ& <br /> Title .1 <br /> Date: <br /> L <br /> -r- r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date T./sh" <br /> Area <br /> Pit or Grout Inspedtion byl;K­�V�� Date Final Inspection by <br /> Additional Comments: LrJS 07-- 4r AG&_ZAA14 <br /> -E Stk 466-6781 D Lodi 369-3621 El Manteca 813-7104 0 Tracy 835-6385I& <br /> Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE C" <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EH1 3-24{REV.1 9 51 <br /> 71771 Q, ai� -)-3'o <br /> EH 14-25 <br />