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�y4 {ff <br /> n <br /> t <br /> APPLICATION FOR PERMIT G-I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 4611^6781 <br /> f; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ixi <br /> (Complete in Triplicate) <br /> Application Is lterabY made to the San Joaquin Local Maeltl+District for a permit ro construe!and install the work harsh!daserleed.Thla apl�reatlon is r <br /> MUM in camphenes with Sett Joaquin County Ordinance No.So for sewage or No. 1882 tot wetlIPum and the Rules and Regulations of the San Joaquin <br /> Local Health 0Wrlct. �. <br /> r lob Address - Lot Sire <br /> �' r` i c�! Address Phone 1 <br /> Owner's Name &- .-- :}! <br /> y�. tr t <br /> ConhaCfM. ia"1 (('s Address __License No 1 <br /> TYPE of WELLIPLt_MP: NEW WELL U WELL REPLACEMENT ❑ OESTRUCTtON O b <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 <br /> In <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. <br /> PROP. LAVE s1; <br /> FOUNDATION AGRICULTURE WELL _OTHER WELL PITS/SUMPS .I <br /> r 4! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t {i <br /> 0 Irtdustdal G Open Bolton ❑Manteca Dia. of Welt Excavation Die.of Well Casing <br /> 0 Domalydc/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> C� Dela Depth of Grout Seal Type of Grout <br /> D Public 0 Other <br /> 0 trriIwiott _.Approx. Depth 13 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dome <br /> Web Destruction 0 Wen Diameter Sealing Material(top 50'1 w ` <br /> Dept Material(Below 501 ; <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION❑ EPA! ADDITION DESTRUCTION C] (No septa:system permitted if public sewer is <br /> available within 200 leet.) = y <br /> Installation will serve: Rancetf ConmerciatOther / + <br /> f Nurtiber of tivhtglunits:—J— Number <br /> Character"of soil to a depth of 3 feet: Water table depth�� <br /> SEPTIC TANK ❑ Type;Mfg _ Capacity No.Compartments <br /> PKG,TREATMENT PLT.D Method of D'mposal <br /> D!stance to nearest: �11eh Foundation_ Property Line <br /> LEACHING LINE ❑ No. d Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well .Foundation — Property Line <br /> SEEPAGE PITS Depth Sire Number _ <br /> SUMPS 0 01vtanas to nearest: Wed Foundation. Property Line _ <br /> DISPOSAL PONDS ❑ <br /> I hereby eertHfv that I hew prepared this application and that the work will be done in accordance with San Joaquin County ordinances,state laws,and <br /> 16t of the San Joaquin Local Health District. <br /> No owner or ageWs signature ce"Ifies the following:'9 cerWY that in the perftxrnance of thew A for which this petrt>it is Issued,1 ahstt not <br /> employ any parson m such mttruter as to become subject to workman's compensatesn laws of Cstihxrtia."Contr*CWes hiring or sub-contracting signature <br /> a` <br /> don <br /> the <br /> foftwft::"1 to t NV that In the pbrformanoe of the wort for which this pem+it is Issued.I shall employ perxrrs subject to.man's corrtpensa <br /> ear <br /> E dfon Waw of CalOwnla.11 <br /> Tl a"appNeart mzsl call for all riui Inspeetlona.Complete drawing on /J� a <br /> t� k Title: - Data: it P <br /> a1 �� FOR D PARTMENT USE ONLY <br /> Application Accepted by MW I 4K _ DataArea <br /> 91 GMut Iropeetivn W Darr�L� Final Inap!etbr►by � <br /> 4Additional Commams: — <br /> 0 Stk 488.678! ❑Lodl 30-Ml 0 Msntaoa 873-7104 ❑Tracy 8354M% <br /> Apptleant•Ratum all toples to:enwinotatanN Magill PsrmiNServices 10V:! It Hazelton Ave., P.O. Boa 1009.Stk.,CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY EIDIATEELPISRUIT,tVO. <br /> INFO <br /> .EN t3.t�rpEY,t.!<et ,•5, Z, , <br /> EN WA <br />