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APPLICATION.,F,OR.,PERMIT
<br /> SAN JOAQUIN,;E.QCA-L,,HAjI�LTH DISTRICT
<br /> 1601 E. HAZEL -0N AVE., STOCKTON, CA
<br /> Telephone (2091 466 6781
<br /> ij
<br /> PERMIT EXPIROS1 �fAR FRAM
<br /> .1:',.,-.li.:.. .:i_.3.. :r;. sl..;. _ r ... :,(CUn'ipi+st$';jn;TTlpheate},4_. _ :,',_ ts•�� ..�i;;:' E.'_. ..
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herej6ldescribeti'S1?iis application is
<br /> made in;co[np00!ncewith San Joaquin'.Goynty;Ordinance,No;_549 fpr�sewago or,No.-;l862.fo r:well/:pLfnp'pnd thePule*,apd;Ragulations;of the;San-Joaqujn
<br /> Local Health District..., ,ws r
<br /> 3Yi t
<br /> Job Address ,A ii, l5_. ,., City Lot Size )PMAi
<br /> Owners Name J}r U � 7.- Phone 2-� S �
<br /> Add
<br /> 3a3�
<br /> Name - `. ...._ :.- .' _.. :.__. -. License RNo. . __.._ ... .._. . Phone;
<br /> :TYPE OF _g1 LM
<br /> YPUP: ; N WELL: ❑ WELL REPLACEMENT ❑ DESTRUPTION ❑
<br /> pU'IhlIP1NSTAI:CATION: SYSTEM'iREPA1R ❑' ,OTHER--p{ -
<br /> DISTANCE TO;:NEAREST SEPTIC TANK S^C} ` i. PROP. LINES
<br /> .. $E1NER LINES
<br /> DISPOSAL FLt],���
<br /> FOUNDATION AGRICULTURE WELL OVER WELL PITS/SUMP$ O
<br /> i
<br /> J PR09LEM AREA CONSTRUCTION SPECIFICATIONS
<br /> INTENDED USE: TYPE OF WELL-
<br /> -i❑ Industrial ❑.Open Bottom ❑ Manteca Dia .of Well--Excavation. - -Dia..of-Well Casing
<br /> -Domestic/Private ❑ Gravel Pack :❑ Tracy Type,of Casing Specifications
<br /> ❑ Public ❑ Other :❑ Delta Depth of Grout Seal Type of Grout .
<br /> _p.
<br /> irrigation - �4pprox.'Depth --:❑.Eastern Surface-Seal Installed-by.: .. :.. -
<br /> L,
<br /> Repair Work Done i ❑ Type of Pum �,: ,b H P -15, Q^ State Work Done ki 02
<br /> ;Well'Destruction ❑ Well Diameter: Sealing Material (top 50') %-f'lf�A
<br /> .......... Filler'-Material (Below 50'}
<br /> 3 �A�
<br /> vV
<br /> ;........ ... ....... p
<br /> .TYPE-OF SEPTIC WORK: NEW INSTALLATION:El ON ❑ (No septicsystem permitted if ublic sewer is;
<br /> REPAIR/ADDITII❑ DESTRUCTION _•__available within 1200
<br /> }
<br /> i installation will serve Residence Commercial'_ Other
<br /> Number 1
<br /> oliving Number of bedrooms
<br /> Ch`aracterof soit-to depth of 3 feet: .. _. . ..... ._ f.:,..i' Water table depth
<br /> PKG: TREAThAENT PLT;❑ � ' Ca aci - Mo Compartments
<br /> SEPTIC TANK ❑ 'Type/Mfg
<br /> Capacity!. eth'od of.Disposal
<br /> iDlstance to"nearest 'Well foundation ' Property Line
<br /> LEACHING LINE C3 .No. & Length of lines Tote! length/size
<br /> sy
<br /> _;FILTER BED ,❑ 'Distance to nearest-,: Well 'Foundation roperly Lina _. _
<br /> f r
<br /> ,SEEPAGE PITS ❑ Depth Size NumberE
<br /> :
<br /> +Sl1MPS ` ..- ❑ Distance to-nearest:; -;Wel! Foundation _ Property Line -
<br /> j__.._. DISPOSAL PONDS ❑
<br /> f hereby certify that':I have prepared this application and that the work;will be donne in'accordance with San Joaquin,county ordirta6ces, staid-taws, and
<br /> rules;-and-jregulat!ons-*f the San Joaquin Loeal-Health.Distract. i_. ..
<br /> Horrie owher o'r licensed agent's signature cert'rfies°the following .'I cel*that ir1 the perforrnanoe of,the work for which this permit is issued,I shall not,.
<br /> iemployarty person-in such manner as to`.becdme subject to workman's oompensation-taws bf:California.'.Contractors'hiring-or sub Fontracting signatilre !-. .
<br /> certifes the following:"I certify that in the performance of the work for Which thls'parmit is issued', I shall erriploy i0irsons subject to workman's compensa-
<br /> tion.laws of-California: j�S _
<br /> : __ _ pec p g side �� ✓/ 4�f+
<br /> gwred ihs frons. Com lite drawing on reverse
<br /> _.... The applicant must call for allVre. _. _ .. ._.... . .- . i _. ,. ...... ........� _ ,_�• �.._ _ . ,...,._--
<br /> Y TSS '
<br /> Signed Xi _ Title. Date:
<br /> �ru A,-P,✓ u�n✓fi
<br /> a - -
<br /> RT `
<br /> USE ONLY M
<br /> FOR DEPARTMENT' '
<br /> i Date r 7 Area
<br /> Pit ar Grout Ins tion b Date Fi'_._.
<br /> Application Accepted by
<br /> 'pec' y ' nal Inspection by
<br /> mmeri 3 r....._
<br /> AdditionalYCo ts:
<br /> . 0 Stk- 466-6781 - ©-Lodi •369-3Fs21 ! n-Manteca -823-7104..-.4,- ❑;Tracy 836-6385 _....:;
<br /> Applicant:- Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave. P.O. Box 2009, Stk.'; CA 95201 i
<br /> iNFEFOi AMOUNT DUE_, _ AM(SUNT 1kEMITTED. .. SH
<br /> RECEIVED.BY DATE iu PERMIT`NO
<br /> -
<br /> EH 13.24(AEV 14!03)
<br /> EH 1426 3................. ......
<br /> . `�
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