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'I mw ... <br /> q APPLICATION FOR PERMIT Uli--;;4 ,—� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT j;A jP,C 1, <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephohe (209) 466.6781 2 C <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r� ` <br /> _. <br /> (Complete in Triplicate) ENVIRC)4it"47ALF <br /> Application is hmeby made to the Son Joaquin Local Health District for a permit <br /> t 1862 on torcwarid/or p atsll the work heivi is <br /> nd the Rules�tyula; f t <br /> mads in compliance with San Joaquin County Ordinance No.549 for sewage r <br /> Local Health District. <br /> Job AddressJ14 City Lot Sine, PM— <br /> job <br /> ?' <br /> owner's Name ��p\\n ��1r Address y`_1g4 ll�.Dr'ha,r, Fcrfy�.cc�Phil" <br /> •�._--.-- <br /> Contractor IA-evll�lrt Address; - License No. I� Pfwne �1�es <br /> t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION <br /> PUMP INSTALLATION 0 SYSTEM REPAIR O OTHER ❑ <br /> (?(STANCE T9 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PRS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI;':CATIONS <br /> ❑Industrial ❑OpenBottom ❑ Manteca Dia.of Well Excavation Dia,of Well Casing <br /> ❑Domastic/Private ❑Gravel Pack Tracy Type of Casing Specifkall" <br /> 11 Publicf7 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - <br /> {_ Repair Work Done ❑ Type of Pumpjo — H.P. State Work Done <br /> Won Destruction `� Well Diameter Searing Material(top 501 c1 <br /> Depth_ Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No sortie system permitted if public sewer is <br /> available within 200 feet-1 <br /> Intonation will serve: Residence— Ccmmercial— Other <br /> Number of living units: Number of bedrooms _ <br /> Character of WN to a depth of 3 feet: Water table depth ' <br /> SFPTIC TANK ❑ Type/Mfg _ Capacity No.Comportments <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to rwsrest: Well Foundation Property Line '- <br /> LEACHING UNE, Cl No.b Length of Ones Total length/size <br /> Line—FILTER BED ❑ Distance to nearest: Well Foundation Property <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I hand ve p spared this application and!hat the work will be done in accordanro with San Joaquin county ordirWlCal,state laws,and <br /> rules areaulations of the San Joaquin Local Health D3trict. <br /> Home owner or licensed agent's signature certirms the foSowing:"I certify ttiat in the performance of the work for which this permit is ksuW.I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Ca6fomia:'Contractors hiring Or wwf}eontraetinp <br /> Certifies the following:"I certify that in rhe perpermit is of the work for which this peris issued.1 shall employ persons subject to wOrt~'s cormpsnsa <br /> tion laws of Calilornis.' <br /> Tho app6eant must can for ale required inspections Co l to drawing on rsyerse side.Signed it'L. <br /> Data: <br /> R DEPARt MENT USE ONLY <br /> Application Accepted by �� 1-' Date r "' f Ar" <br /> Pit or Grout Inspection by Date Final Inspection by Daf� <br /> Additional Comments: _ <br /> ❑Stk 486.8781 ❑Lodi 3td-3821 C1 Menten 823-7104 Q T•scy 8354386 <br /> Applicant-Return all copies to: Environmental health Permit/SerAces 1801 E.Huelton Ave.,P.O.Boz 2008,SdL.CA 26Zrl1 <br /> FEEA>AAOUf1T DUE AMOUNT REMITTED RECEIVED BY DATE PERMn-NO. <br /> INFO <br /> ♦.Eli t}71 tItt1I.5/Kay ��� �O�p <br /> F)1147N •- <br /> w� .rlraa�:�'..1.p,• ti'« '�+��-'i�.v',,$�/lVl�:'v ,.d,..,-;}v: .1.4�+.�1-.i�,.r.« ..,..a.... .� ,..s. V. <br /> T J <br />