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{97oN /71�2iNG WtGLS <br /> • <br /> APPLICATION FOR PERKO <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. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/pump and the Rubs and Regulations of the San Joaquin <br /> Local Health District. ii�����,y99��,.�J'�' <br /> Job Address D -f e-Prl sD O V/ TLC C�Z city L— Lot Size <br /> �/� PM <br /> Owner's Name nATy— Address 26 � J 4Qyfe1S0?1W r`7/ Phone <br /> WS+!} 0Ewaopk" NT '220 N, £Asr Sf) Wo`DLa^'D 283-326 C9/� L2Zz9 <br /> Contractor PXL feCA Address 1(e 3P icense No.YO.72V Phoned///34s9-09- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 5,/L (3�RlNGS <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER"YL/NoNl7u,¢/N(r WtIIS <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatiro n /o Dia. of Well Casing <br /> ❑ Domestic/Private Gravel Pack Tracy Type of Casing J/ SC/t FO Py6- Specifications - <br /> El Public ❑ Other ❑ Delta Depth of Grout Seal 5C /TAArL,.,eul Type of Grout /° Nt <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ElWell Diameter >✓ Sealing Material(top 80') Cr A✓Ct PN C A/CQ-IL C&Ulk l <br /> Depth 'i t.- /1J/r tA,_,tH7 Filler Materiel (Below 5g') Aerilpwik 4geb,10"jkP <br /> TYPE OF SEPTIC WOVfftt: <br /> LLATION ❑ EPAIR/ADDITION ❑ TRUCTION ❑ (No septic system permitted if public sewer is <br /> VrbtyeeLihm <br /> eet.) <br /> Installation will serveCom rcial_ Other . <br /> Number of living uner of rooms <br /> Character of soil to pth <br /> SEPTIC TANK Capacients <br /> PKG. TREATMENT Posal <br /> to nearmt: Well Foundation <br /> LEACHING LINE ❑ No. & Lang of lines otal length/s <br /> FILTER BED Distance to n rest: Well Foundation Property <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Fou tion Property Line <br /> DISPOSAL PONDS ❑ <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 /> rules and regulations of the Sen Joaquin Local Health District. <br /> Home 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 comperaation laws of California."Contractors hiring or sub­contractirp signature <br /> certifies the following: "I certify that in the performance of the work for which this permit Is issued,I shell employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic t mus cell for all required i pe ions. Complete drawing on) side. L/0 pD WA" -CGy00- <br /> Signed Title: ��� Data: z8�� <br /> p FOR DEPARTMENT USE ONLY p p <br /> Application Accepted by Wn rHA� Data O a Ansa X0 <br /> Pit or Gtou Inspec Ion by >AJ, tf'Ntallitilipectipri bY D¢la� � <br /> Additional�me is / - <br /> ❑ Stk 488-8781 ❑ Lodi 388-3821 ❑ Manteca 873-7104 O Tracy 83683% <br /> Applicant- Return all copies to: Envyonmentel Health Pamit/s leol E. Hazelton Ave., P.O. Box 2009, S ., CA 1 <br /> AAdoh r- 3S, 00 � .rv. . <br /> FEE AMOUNT DUE AMOUNT REMITTED CASHRECENED BY DATE PERMIT N0. <br /> INFO <br /> . EH 13-24IREV.haat <br /> EH 1425 <br />