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<br /> APPLICATION FOR PERMIT
<br /> SAN JOAQUIN.LOCAL.HEALTH DISTRICT
<br /> • 41
<br /> 1641 E. HAZELTON AVE., STOCKTON, CA
<br /> i elc.,ir.ne 1209} 466-6781
<br /> ` PERMIT EXPIP 1 YEAR FROM DATE i,,SUED
<br /> (Cor,il wte in Triplicate) +
<br /> F
<br /> 1 Application is heeaby mode to the Sen Joaquin Local Hearth D�trkt for a permit to construct and/or Install t
<br /> :. he work hcra)n tlestribetl.This appllcatan bti f
<br />( ,nude rdinance No.649 for stnvage or No.1962 for well/PUMP and the Rules and Repu4tions of the Sen Joaquin
<br /> t.
<br /> an compliance with San Joaquin County O
<br /> ;� 4pcal Health District.74
<br /> '.' ; k)
<br /> fq��4�', �'l� ity� Lot SizeO Its/ PM E' C S
<br /> —
<br /> / - a g� ro2bi7� Phone '
<br /> Address .-
<br />#
<br /> Phnno 65Y a.
<br /> �,-Contractor Litrrnse No._L 1
<br /> f P ti.er, WELL REPLACEMENT 17 DESTRUCTION 0 "T
<br /> TYPE OF WELL/PUMP: NEW WELL ❑
<br /> SYSTEM REPAIR ❑ OTHER ❑
<br /> :< PUMP INSTALLATION ❑
<br /> }+sr'3f DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES. _ DISPOSAL FLD. _ PROP. LINE
<br /> :,..; T �G❑„+: FOUNDATION' _ AGRICULTURE WELL _
<br /> _OTHER WELL PITS/SUMPS f
<br /> :.,INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAil0a+15
<br /> • + i'` ❑indu�trlal F. ❑Open Bottom C1 Mem9ca Die.of Wall icxCavatlon Die.of Wali Casing 1
<br /> ! y”
<br /> } l t•: Specifkcateons
<br /> ❑Tracy TYPa of Casing---
<br /> 0 Graves ck
<br /> ,U❑,Domestic/Private '
<br /> 7 o},Grout
<br /> r ❑ Delta Depth of Grout Seal {` Type
<br /> rA''1S❑Public '4 ; ❑Other
<br /> rex.Depth.' 0 Eastern Surface'Seal Installed by ;.
<br /> -i 0.irrigatwn _J►Pp { _ Stet e Work Done
<br /> u y1 f!vt t� RepairWorkDone ,❑ , —, ;Pe of Pump H.P.
<br /> Weil Destruction, Well Diameter Sealing Material(top 50'I,:
<br /> Filter Material(Below 60'1 . l'ir k
<br /> Depth
<br /> en l4t '�rTYPE OF 5EPTIC;WORK:, NEW INSTALLATION REPAIR/ADDITION❑ DESTRUCTION❑ (No septic system permitted if public newer is J
<br /> available within ZW feet.) m,
<br /> !-ij•'1
<br /> Nation will servo:` R lice! Commercial_ Other + )
<br /> 'r E �' z unats: Nur-tcr c}bedrooms l �` 20
<br /> * Nurnber of);ving,
<br /> Water table depth
<br /> r ski ,fharatlar,ol so6'to a depth of 3 Teel:_ No. Compartments
<br /> +� TIC,7ANX ❑ ' Type/Mlg _ �iQ `e — Capacity.
<br /> Method of Dt I
<br /> TREATMENT PLS•❑
<br /> ( E, /�0 ' Q r.?,Property Line
<br /> •,t'. ''_ Deltance w nearest: Welt Foundation�L., r
<br /> dry
<br /> '00 ` EEAC�IiNG UNE i ❑ .No,8 Length,of lines 7 rota!lergthlsize''
<br /> 0.4 '' Foundation Property Una
<br /> FlLT9 BED`( ; ❑ Disianco to taste t: Wall _. r. 4'
<br /> t#?ijl SEEPAGEVPITS. r r`E, ❑ Depth ...—Size Numb9r ;Y
<br /> SUA+IPS) ❑, Distance to nearest Well _ Fouiadation r�roperty Lino'
<br /> r :rr OISPO`_AL
<br /> -PONDS C]
<br /> i rrrt 1 herapy'oarti(y that I have prepared this application and that the work wilt be done In accordance with Sen Joaquin county
<br /> ordinances,state laws and
<br /> s .,a - _-..a,..LSc'..i
<br /> gI.Jimi"'And rogulatiprr.of.the San Joaquin 4ocal Health District.
<br /> r "J,a..•HOn 4 104;n r dr lipenrxrd agent's signature,certif les the tollowing:"1 certify that in the performance o!the work for which this permit is i laden 1 shall not o
<br /> U � 'errrpNly any paten in 3kich rt,anner aa.to�ecome.subject to workman's oompensation.laws of California."Con{rector's hiring tx sub contracting signature
<br /> yr Pp eortMres the fothwing:"I certify that In'thtr performance of the work for which this pennit Is Issued I°haR employ persons subject to workman a con penes
<br /> u' 't,on4+wa of Criifomla.''. t
<br />.{ a ,.Tile al t cal fired i apeetiona'Complete drawing on reverse side e'.
<br /> ra
<br />` t•,q1" rt Slgrod X^ Tide: Data ! ?
<br /> DEPARTMENt.Ub ^ONLY �
<br /> Date
<br /> { ),.t s AppliCetfon Accepted by
<br /> y tri Final inspection by Date ^k�r
<br /> r� Pit or G,out:Inspection by Date. fro r
<br /> ► e¢ 't`Adilklorwtl CorrnnenG6
<br /> rF h f+ ❑Stk`;,!IBb8781 ❑Lodi 369.3621 ...❑Manteca 1!2.1.7104 ❑Tracy ,835.93115
<br /> t a..y�wry r,AppBeant;Return aq ooplsa to:Environmental Health Permh/Servloss 1801 E.Hazelton Ave;.P.O.Box 2009.Stk.,CA 9=1 4 }�
<br /> t�
<br /> ?
<br /> 4 r f7*S 1 FEE
<br /> .:,AMOUNT Out• AMOUNT REMITTED CASH
<br /> RECEIVED BY DATE PERMIT'NO. is
<br /> Ij1tT��,'.$i,A1Yr�n+'f:S4�:,k•t1.L..uvw.t..•r..+. s '' ��yi'rlr:l.,���� � s
<br /> • Nk' - �f YI '�P' - I''' '4i' +.., t ...,�• „ ..�<. -.,.Y\Kf ,� :,t:c i5
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