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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> TetephDi{e (2091 466.6781 <br /> PERMIT EXPIRES Y YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> t - rmit to construct and/or install the work herein described. 1Ms <br /> Application is hereby made to the San Jo�utn0 A��No�or fsewaga or No.186'2 for`veil/pump and the Rules and Regulations of the San Joaquin <br /> made u compliance with San Joaquin County _ <br /> Local Health District. I 1k/ase _ PM <br /> r �— City Lot Size (� <br /> Job Address nJ� Pt,gna5 --�(tS 3 '. <br /> Address v 7 _. <br /> owner's Name '� C y 3 Phone fOt� Q <br /> ^License <br /> Address ' DESTRUCTION ❑ <br /> Contractor !` WELL REPLACEMENT ❑ T OTHER ❑ <br /> NEW WELL ❑ <br /> TVPE OF WELU PUMP: 1'�SVSTFM REPAIR ❑ PROP, LINE -- <br /> PUMP INSTALLATION O v . DISPOSAL FLD. <br /> / SEWER LINESc- C- , PITSISUMPS . <br /> DISTANCE TO NEAREST: SEPTIC TANK, t.�_ r, OTHER WELL <br /> AGRICULTURE WELL + <br /> FOUNDATION + � <br /> +-•,:rypE OF WELL PROBLEM AREA CONSTRUCTION SPECIFi"noNS Dia.M Wom C36 _ <br /> INTENDED USE �--• pia,of Wea Ezcavattort S <br /> O dpap Bottum ❑ Manteca...„ - Speeifica'tbns ` <br /> ❑ industrial Tracy e Type of Casi Type of Grout ------1. <br /> ( -❑ Domestic/Private a Gravel Pack Cl�re�+^ Rowh of Grout Seal <br /> ^� Public n Other. _- / Surface Seal Installed bV <br /> y�yox-p�gt 1 1 Eastern State Work Dara <br /> { I Irrigaocm H.P. ' '4 <br /> Repair Woh Done ❑ TYps of PumpSmIling Material tropC- <br /> ❑ ameter <br /> : WeN Di _ _ <br /> Well Destruction �v,- Filler Materaat(Below 50'1 <br /> r•�t mored it public cev+er is <br /> REPAIRIADDITION l I DESTRUCTION I i �a��wI i 2W feet.} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t) .ptA - <br /> �si, �JhstalYdtion will serve: Residerice <br /> Comm a c"d <br /> Number of living±nits �.._ <br /> Number of bedro s Water table depth <br /> Character of sal to a depth of 3 feet: - ' Capacdy O No. Compartments <br /> Type/Mfg •�' 1 <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT- ❑ inw -rte Founder �_ Property Luwl_ - <br /> II -Distance to marest: Weg> <br /> __ 0 Total length/size �-?-- <br /> LEACHING LINE W No $ Length of Imesf Foundation « r� property Lure <br /> FILTER RED ❑ Distance to nearest: Well <br /> /Number Cb <br /> SEEPAGE PITS 4 f Foundation I It) 1-- Pro'}'/�'e <br /> SUMPS ❑ Distance ro nearenY Well.1� <br /> I and <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be dorre in aeeo^r ance ofh� �O°q e%vork for �h hcoumis permit issued, I shall ll not <br /> rotes and regulations of the San sJrg aturequin Local Health certifies the follow <br /> "'1 cattily that in the pert <br /> Home owner a licensed agern' rsons subject to workman's compensa- <br /> Homey any parson in such manner as to becomes th ec o Eos r which „s permit issuedrtl shall employ pe rs hiring or subcontracting signature <br /> offm work <br /> S c.nitias the foaowing' "1 cMify that h the perforrr+ertce <br /> I __ tion laws of California." Complete drawing ar reverse sad / V �J <br /> The applicant at (a" or all requir T 2J o /i <br /> 1 <br /> I r <br /> Signed X _ - <br /> r - - - t FOR-DEPARTMENT USE ONLY /)'� <br /> t _ ry;,r' er..J- .A„e'"'""'- Date Areajf <br /> Application Accepted by Date <br /> ����� Dat Final Inspection r&or Grout Inspection by .--r�.rT-- i r. _ <br /> P1 w-t� <br /> Additional Comments: ❑ Memeca 823-7104 ❑Tracy �$3✓� <br /> C SO, 466-6781 .. ❑ Lodi 369 3621 P.O. Boa 2009, S*_ CA 95201 <br /> Applicant - Retum all copies to: Environmental Health PIRmit/Services 1601 E. Hazelton Ave., <br /> 1 CK RECENED By DATE PERMIT NO <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> - <br /> t <br /> W4(REV - <br /> E11 tt 1a <br />