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t APPLICATION FOR PERMIT 1110 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—i ON AVE., STOCKTON, CA (�J <br /> ' Telephone (209) 466-6781 �— <br /> PERMIT EXPIRES VYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> calis hereby made to.the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This a <br /> ,do in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weRlpump and the Rules and Regulations of the <br /> cal Health District. <br /> ' b Address /I W 7 �„ ` Q h N M�Pj City /'Lot Size LZLG[./p r-< PM <br /> vner s Name..r 'f a f'+1 eSI1 / wl _1CDAddress ('Rt�,j1 2 �!►'t hQe4 t' Phone 40 <br /> ' mtractor 1 dt 1je-y-'Q `/=!•�+�:-„..Address-, -0- �]f�yt^-7 6A/License No:o1d1 R 1 Phone 3 <br /> 'PE OF WELL/PUMP: NE ELL' WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X. SYSTEM REPAIR ❑ OTHER ❑ <br /> ' STANCE TO NEAREST: SEPTIC TANK 12VG SEWER LINES DISPOSAL FI-D. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSJ�I <br /> INTENDED USE TYPE OF WELL _ PRO'BLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ' Industrial >41 pen Bottom ❑ Manteca t - Dia. of,Well Excavation Dia. of Well Casing _ <br /> 11)UM"tic/Private ❑ Gravel Pack ❑Tracy, Type of Casing =502e- Specifications �pt � <br /> Public ❑ Other F ❑ Delta Depth of Grout Seal t Type mol G7rout <br /> ' Irrigation ApproN. Depth 'I I Easteni Syrface Seal Installed by- l e V 0&2L�/!_ ti A <br /> rpair Work Done ❑ Type of pump - K HSP. 1 �- State Work Done_ <br /> ell Destruction ❑ Well Diameter l Sealing Material (top 50') <br /> Depth I Filler Material 18elow 50'I <br /> IPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR'PADDITION LI DESTRUCTION II (No septic system permitted if public s, <br /> ` available within 200 feet.) <br /> Installation will serve: Residence_ Commercial ' Other <br /> ' Number of living units:— Number of bedrooms <br /> Character of suit to a depth of 3 feet: Water table depth <br /> :PTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> :G. TREATMENT,PLT. ❑ , Method of Disposal <br /> Distance to nearest: Well Faundalion Property Unto <br /> ACHING LINE d' ❑ No. IN Length of lines _. __ Total length/size <br /> t LTER 86D—"J ❑ Distanfe to nearest: Well Foundation Property Line <br /> 6 <br /> _EPAGE PITS I Cf Depth Size Number- <br /> �...r...,.......�., <br /> JMPS � ❑ Distarilce to nearest: Well - 1 Foundation ^`- � -��ProperlyLiro <br /> ' ISPOSAL PONDS ❑ Fr. r""""te"•"r 1. <br /> tereby cenify that 1 have prepared.this application and that the wotk Alff be done in aecordanaSWO;San J6quin county ordinances, ata <br /> las and regulations of Me•San Jos4uin L"IlHealth District. 1 t <br /> orae owner or licensed agent's signature certifies the folow.ing: "I certify that in the,performance of the work for which this permit is issue <br /> ' nploy any person in such manner as to become subject to workman's compensation laws of California--Contractor's hiring or sub-contract <br /> ,nifiss the following:°9 certify that in the pormance of the work for which this permit is issued,I_shall employ persons subject to workman' <br /> m laws of California." rybn <br /> to applicant must call for all iequired inspectibns. C;omplets drawing on reverse side. - <br /> r <br /> fined Kq F.. <br /> S� m 4yy� tSAn bA"^ Title! <br /> P r`YCr •C _ Date: <br /> a DEPARTMENT USE ONLY - <br /> / O <br /> pplicatian Accepted by • Dote/ Area <br /> t or Grout Inspection by ° OaidP Final Inspection'Ify ate <br /> s <br /> dditional Comments: <br /> Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 , <br /> pplicent�,Retutnall,coples to;,Environowntal.Health,P,ermk/Service_s 1001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F1'` ti <br /> t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br /> INFO p (`T�^(�1 /jjJ <br /> 4(REV.r/AS) ��. y. .� ✓ ✓( s�" IL3 21 <br /> 6 <br />