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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E HAZELTON AVE , STOCKTON, CA <br /> -� Tejepho6e 12091 46641781 <br /> PERK41T EXPIRES Z YEAR FROM DATE ISSUED <br /> (Complete In Tdplieve) <br /> Apptmaation in hereby mach so 4-M San Joaquin Local Health Dlatriet for a ptatrat to eonarruct Wdlor knallif the work herein tlaacribad fills applotbn Is <br /> M01:10 in compiianCe with Sen Joaquin Coutity Ordinance No 549 for eswage or No IBM for wap/pump and the Rules and Ragulatlona of the San Jeactuln <br /> Local Health District <br /> Job Addretr 4 City 8t—k t e.n Lot site "Co PM <br /> Owners Name Addrea ,76S MmI lmngda W$X_ .__ Phone 6 <br /> Contractor._E12gate Drill int; Address_'4942 flronnanH „, fewomilreenss No 4o153f1 Phone _ p <br /> TYPE OF WELL/PUMP NEW WELL P1 SWELL REPLACEMENT 0 DESTRUCTION C) <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER C7 <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES __30' DISPOSAL FLD PROP LINE _ n' <br /> FOUNDAT}ON AGRICULTURE WELL OTHER WELL--&—ZITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IR Industrial ❑Open Bottom ❑Manteca Dia at Wen Excavation -10" � Dy of Wolf Ca” !' <br /> ❑DomemiclPrivate Ck Gravel Peek ❑Tracy Type of Caaung__rk'h 90 F109(1 Spacificatbrn 5% EtWA=dtae <br /> 1`1 Public f-1 Other 154 Datta Depth of Grout Seal 15' Type of GroutMeeh Ow wt <br /> I I Imption 4QLAppos Depth I 1 Eaetarn Surlacs Sea!Inetansd bye abaft <br /> Repair Work Dona ❑ Type of Pump H P State Work Dose* <br /> Wall Wetnection 0 Wen Diameter Sating Material flap 50'1 tin& OWMrIt yA% 5% esti=M0 <br /> Depth flow Materitl(Below 50') <br /> TYPE OF SEPTIC WORK NEW INSTALLAT40M I I REPAIR/ADDITION I I DESTRUCTION i i I Wa wptee system pemuHad 4 pubic sewer,s <br /> _ a'»ntable vntnan 200 feet) <br /> "E Inlitapsfmon will serve Residence— Conwnardor <br /> al_ Oth <br /> Number of raving wits Number of bedrooms <br /> Character of sal to a depth of 3 feet _. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capanty No Compwtftmto <br /> PKG TREATMENT PLT ❑ Method of Diastase! <br /> Durance to naerein Wan Foundation Progeny Lina <br /> LEACHING LINE ❑ No 11 Length of Was Total length/sue <br /> FILTER BLED ❑ Dratance to ne4rost Wap Foundation I Prop"Uro <br /> SEEPAGE?ITS I I Depth Site Number <br /> SUMPS 0 Distance to ttaa.ain Wep Foundation property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have papered thio application and thin the work wap be done n actorder"wish San Joaquin seunW adlnal►mm stem Iowa.and <br /> rides aid ra pAations of the San Joaquin Local Healeh D7lrret <br /> Name owns of ilcarlptl 29NWG signature o tym the follow" 1 DOWN that in the psrformenee of the work for which this perrrdt fa isa►ed I sdnaA not <br /> ampioy any person In such manner ea to become sublaet to workman's eonepansatlon laws of Canfornia 'Contractor's hkft or subeontnclang signature <br /> ce"MIS the following '7 ceroh'thin on"u perltxmnence of the work for which"permit is ensued I chap employ person subject to workman is camperna <br /> tion Iain o1 CcWwnla•• <br /> Tisa apptic4rlt mus ap fpr all re rpeetlomr Comple'a drawheg on Aida <br /> Spn.e Tin. '�';�+�,�lrL a:. 91-6 <br /> POA DEPARTMENT USE ONLY <br /> Appkador►Accepted by Dam Aron <br /> Ph or Grout hupe*tion by Date Final Inspection by Dam— <br /> Addkkuwt Comnrnts <br /> ❑Stk 416761 ❑Lodi 389.3521 ❑Manteca rix!7100 O Tracy 1135-6985 <br /> APWkant Rdwm 40 copies to Emwironmenml Health Permlt/Servkn 1001 E Hazelton Ave,P 0 Boa 2009.Stk,CA 81j,231 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED eV DATE PEAIM4T 1l0 <br /> ♦IH MIA IR1V 1e•el <br /> IN 14-71 <br />