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t .. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> !Complete in Triplicate) <br /> Plication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This ap <br /> ' de H compliance with San Joaquin Gounry Ordinance No.50.9 for sewage or No. 1862 for well/pump and the Rules and <br /> do Health District. 1' <br /> 1.1 .r Regulations of the S: <br /> Address L�1 l e ( I.rs fy <br /> -- Ciry 2/'N,p l7 Lot Size_ ) & < <br /> tar's Name � Q � a ,A ) � / '_' !L__`"� PM- <br /> Address c�1� Al W w k n a <br /> L ('1 <br /> ' Proctor n� Address .1 i (�. �ne tJ n N a,r <br /> E OF WEA LL/pU(yp: Phone <br /> r LSA% 7 License No.�„��3 gaPh,,, 3 ev . <br /> NEW WELL.,CZ g <br /> WELL REPLACEMENT ❑ <br /> PUMP INSTALLA-TION g� DESTRUCTION ❑ <br /> 'ANCE�$NEgEgT-^SE1+7fC-TA-RIC"`R O„J ' ,SYSTEM AEPAIR:fl OTHER ❑ if <br /> SI:VVER�CINES :::-ire-A�.^. <br /> FOUNDATION LO ri ” '"brSPOSAT'Fl-D �-pgOp-LINE-ae-` <br /> .-. AGRICULTURE WELL <br /> dTENDED USE`:a TYPE OF WELL p OTHER WELL Q�_ p175/SUMPS <br /> iustrial ROBLEMAREA a CONSTRUCTIOtU_$PECIFI'GATIONS <br /> :Open'Bottom . - ❑ Manteca 3 Dia. of <br /> :mastic/Private `❑ Gravel Pack y �f ell Excavatiari"� Dia. of Wall Casing <br /> ❑ Tracy Type/of Casing_�Y/u� <br /> bbq ❑Other ❑ Delta '` Specifications j <br /> Dation - +D ,Depth of Grout Seal 10 <br /> _Af pumulx Depth I I Eastern Surface Seal Installed'li //AA Il! Type of Grout ire <br /> ' Work Done ❑ Type of pump J b H. _ r i y r <br /> lestruction <br /> ❑ Well Diameter ' Slate Work Done _ r <br /> r ,�\�Sealing Material trop 50') °'��:?°, <br /> Depth —�Z` Filter Material (Below 50.'p✓/! 1 <br /> OF SEPTIC-WORK: NEW INSTALLATION V) RE <br /> OF <br /> ESTRUCTION I (Nowt <br /> r // septic system <br /> 118tion will serve: 'Residence ' ` ~ Permitted if public sewer <br /> CommefcialsisL_ ava4able'�within 200 feet:) <br /> iter of Jiving.units: „WNumbei o(b ms - : {Jj <br /> ' acter,of sol)todepth - ` j 4, <br /> Q^�x - f <br /> Water table depth <br /> IYANK ❑ Type/i`y/g 1... Capacity .<'1:.: ..r <br /> REATMENT PLT.❑ yf( 'r No. Compar"nts <br /> d Method of Disposal r <br /> ' Distance to nearest: Well sF_' diion -1 '__”"-"-""`" <br /> ;! Property Line i <br /> NG LINE D No. & Length of lines t Total length/size <br /> BED ❑ Distance to,nearest: Well Foundation <br /> .l Property Line E .'-'E <br /> E PITS II Depth •I g(� r <br /> fNumber 1 J <br /> I CI Distance to nearest: Well' Foundation(AL PONDS ❑ { +- Property Line , <br /> certify that I have prepared/this a tion and that the work wilt be dare)n accordance with San Joaquin coca <br /> .ke <br /> !'regulations of the San Joaquin Local Health 6istrict. - _ q _._�ty�ordinance_s, state laws <br /> vnar or licensed agent's signature certifies the following: °'I certify that in the performance of the work for which this v, <br /> ' ashe <br /> ny person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring o�subconh sub-contracting he following:'9 certify that in the performance of the work for which this permit is issued,I she.employ Contractor's <br /> subject to workman's comp <br /> of California.' <br /> Hcant <br /> mug' call for all required'napections. Comdata drawing on reverse si <br /> llde/.y. J- ( O lrd/l A'" v7itle: Fi/ ,C- <br /> Dasa: <br /> R DEPARTMENT USE ONLY e <br /> in Accepted by' �`p Date. d" 1'ZJV Area� O� <br /> rut Inspection by V Oates 1 Fina( Inspection by G'7" <br /> q ^ v Date �']� <br /> I Comments: IV C7 F� �.rc� ,�� I.y _ Y� <br /> t 66-6787-P"p Lod) 369-36-21 ❑ Manteca 8237104 ❑Tracy 835-83&5 r - <br /> Retumall codes to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BOX 2009, Stk.; CA 95201 <br /> FEE AMOUNT DUE 'AMOUNT REMITTED <br /> ' INFO CASH RECEIVED ey DATE <br /> PERMIT'NO. <br /> a51 <br />