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APPLICATION FOR PERMIT <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applinuon is hemty made to the Son Joaquin Local NealtIn f btr,,t for a permit to construct and/or install tin work herein described.The sOdketim e <br /> made in compli,nce with San Joaquin Comte Ordinance No. •49 for,,wage a No.1962 for well/pump and the Rubs and Regulations o/the San Joaquin <br /> Local Hcalth District. <br /> Job Address ! • `w S A C Line 6b, Lot Size PM <br /> Owner'a Name AQl •`^ZArI'[A(�_ Addr6s9 _V� � _ Phone <br /> �/ , License No )93dS Phan 3Y—S/�� <br /> C. Contractor tS Addles <br /> TYPE OF WELL/PVAT: NEW WELL rl WELL REPLACEMENT�/ DESTRUCTION <br /> OTHER ❑ r <br /> PUMP INSTALLATION L• <br /> SYSTEM REPAiR i <br /> _ SEWER LINES __ ^ - OSAL FLD.I life PROP. LIN:�d <br /> 715TA':CE TO NEAREST: SEPTIC TANK _ OTHER WELL PITS/SUMPS _ <br /> FOUNDATION AGRICUL.ARE WELL — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SrECIFICA� Dia.o/Well Casing S <br /> ❑In Irul ❑ Open Bonom ❑ Mameca Dia.o/Well Excavation�L Speciflotione <br /> TracyType of Casing Spec <br /> k/Private 7n Gravel Peck ❑ Delta 1 Type of Grout <br /> fI Public fl other fl Delta Depth of Grout Seal �a ' , <br /> 1 I iAce., Depth I I Eastern Surface Seal Instated by •a lis .•.r <br /> Woo -- — <br /> Reppaairr Work Done [] -'rDe of Pump �� State Work Dona H.P.� <br /> �L/i jaV4 VI <br /> Q Well Destn¢tion ❑ Well Diameter _ Sealing Ma'-dill(:OO 501 r <br /> .t93 Depth—.- filler Material(Salow 50'1 _ .ar <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I DESTRUCTION 1 available within 20(No wpuc system 0 fear. <br /> wd�I Public seven b ,- <br /> InsmUation w^!I serve: Res;denca_ COMM816-1__ Other— <br /> Number <br /> t�! Number of bedrooms C <br /> �.. Numwr ul living units:—_ Water Lith depth <br /> Character of soU to a depth of 3 feet:_ CapacityNo.Compartments ' <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG.TREATMENT PLT.❑ Property Lim <br /> S' Distance to nearest: Well Foundation <br /> Total kngtb/size <br /> NG LIN'_ C1 No.IS Length of lines <br /> FILTER Ll Line <br /> - <br /> FILTER BED Distance to nearest: well Foundation 5t <br /> SEEPAGE FITS I I Depth Sze_ Number )k <br /> SUMPS Ll Distance To r ali Well Founpation_-- Property Lim <br /> DISPOSAL L PONOS ❑ <br /> 1 harsh,Certify that 1 have Prepared this application and that the work will be done in accordance with San Joaquin county vhrlamM,sate Taws.and . <br /> rube end regulations of this San Joaquin Local Health Diktrlct. _ fis,which SMU not <br /> Home owner be licensed age� signature to wrifies'he <br /> subject Ao�wwkrmn scertify comtpensationlews ohat in the f CafifoMiie Calnact�hiring w SUls Coma bactirglsignature et- <br /> LS <br /> eoJa he Denon I v. <br /> certtes the following:"I certify(net in Im performance of the work for which thin permit is issued,1 shall empty persona wbjxt to workman's compertsa- _ <br /> tion laws of C,gforri <br /> The applicant must call for NI'squired inspectior:a. Complete draw:nq on reverse side. 1 ) I <br /> �a/W.i-TLl J!/i Date: <br /> x <br /> .tAs� Title: <br /> $pned x " <br /> FOR DEPARTMENT USE ONLY <br /> Date AArea <br /> ^� <br /> Appircarion Accepted by, U^"' -ham S AL1 , `a— 2 'S-12�� iJ _ Dat Final inspection .1�r" _ Oets <br /> Pt or C/ Inapactbn by F <br /> Additional Comments: <br /> ❑Stk 466-67Bt ❑ Lodi 369-3621 ❑Manteca 623-7100 ❑Tracy 83rB70.5 J`, <br /> '[ Appacan0-Retum a6 copies Eirov <br /> es to: nvrmnral Health Permit/Services 1601 E.Hazehon Ave., P.O.Boa 2009,Stk., CA 952011'yt <br /> S AM <br /> EV. OUNT DUE AMOUNT REMITTED a a RECEIVED BY GATE PERMR N0. <br /> t; INFO ZYS� <br /> ' .UI 4N Iali eei <br /> /OSS L fly• oo C s��/i g <br /> FM 14M <br /> srraF.tB�-'�- aYi�aH'Y/.+erar+.+e ^'R@_a'�au#1��;IFKY.tl�—•w+VM4'•zaw "1L� _... .. �. <br /> l <br />