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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAI, HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON• CA <br /> Telephone 12091 466-67d1 <br /> FERMIIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Applic_rhnn <br /> Led.This ion!s <br /> is Nx_by maJ,to the San Joaquin.Lorat Hea "' <br /> lth strict for a r+ermrt•e comtruct+ndlor vtsraa the work herein descranjo , <br /> mad!w rnngtli,mro with San Joaquin c: rry Ordinaanncu,N­!49 for sewage or No. 131:2 lo.v.etV pump and the Rules and Regulations of the San aquin <br /> locel Hcallh DrStllct. /. <br /> /�� , CJ57-1,i kit s t t C�Y�itY/'��'�C CLQ Lot Siie _FM <br /> Job Address <br /> Phorm---- <br /> Owner's NameI .� -"Address <br /> A ._.._—. <br /> J / L Addfrs, ►_•P_ xJ<W5 Lia•nse No`s J"`•'•�Fhone_ <br /> {} t TYPE OF WELL/PUMP: --• NEW WELL E 1 <br /> WELL REPLACEMENT i i DESTirUCTION (_.1 <br /> ------ r SYSTEM R':P".-R 11 OTHER C <br /> PUMP:NSTALLA TION <br /> — DISPOSAL FLD.__ ___ PROP.LINE <br /> DISTANCE TO NEAREST: -'TIC TANK _— SEWER ONES OTHER WELL _PITS/SUMPS _— <br /> `— --- <br /> FOUNDATION _—_ AGRICULTURE WELL <br /> _-_-_ --•- ` <br /> —INTEI�DEO USE TYPE OF WELL PROBLEM ARFA CONSTRUCT <br /> ION SPECIFICATIONS <br /> E.)Industria( U Open Bottom fT Manteca Dia of Vle.11 E.ravat on——�---. SI�rte Well Casing <br /> Type of Casing <br /> D Demeshu Private L1. ions <br /> Gtev^!Pack l7 iracY Type of trout <br /> 1-1 Other i i Delta Depth of Grout Seal <br /> I"1 Prolir. -- <br /> I I Irngsiion Approx.Depth 1 I Easter.! Surface Seal Irntalled bY.----- <br /> Repair:Mork Done i.i Type of Pump _— H.P.---- State Wr_rk Done —• <br /> Sealing Material 4uP 501 <br /> Well Oestrucron %1 Well Diameter ._-_. .__ <br /> Depth <br /> Filler Material IBnlow 50'1 _ --------- —'- <br /> 1 YPE OF SEPTIC WORK: NEVV INSTALLAI-ION t I HER!ADD1111)N t I !)ESTHIICTION I I available within x200 feet.) it pr.blw rower tf, <br /> Installation will serve: Residence__ Commercial_ Other_._ \ <br /> Number of living units: —_ Number of bedrooms <br /> Water depth <br /> Character of so'I to a depth of 3 Ieer�^* -- a /I No.ComDarhtlants C•• <br /> cr Type/Mfg <br /> L.C6LC'�Cf __ L —`Oer*,uty.�-k'vSr <br /> SEPTIC T;.NK Method of Dispr»al <br /> PKG. 7REATMENT PLT.Cl Property lkle <br /> Drstanc4 to nearest: W611 Fourtdalicn. <br /> T�- C <br /> T mal longth/sire <br /> ZZ) <br /> LEACHING LINE f.4---No.8 Lorgrh of G^et. — --- <br /> FILTER KD ❑ Dis^arrif.to nearest: Well _., <br /> Foundation prrlp ny Line_ <br /> a -- ._.—_Size— Number j--- •- <br /> i SEEPAGC PITS I; plh / <br /> /p,, Foundation! Property line <br /> 3U.':tPS t(/ D�Jance to nearest: Wil:_ <br /> D!SPOSAL PDS f I <br /> ' I Hereby ceaily That I have prepared!his application and that the work will be dune to accordance with S+n Joaquin eounty,ordirNneaa,state ktvvs,and <br /> �tt <br /> Fulfil;and regulations of the San Jnsquin Local Health Div--ict. Ia klsued•I shall not <br /> Home owner or licensed agent's signature <br /> certifies the following:"1 certify that in the perlonnance of the work td trrhtch'ng or nutsfhb permit _ <br /> employ any person in such nner as to become object <br /> to he rk►for which this rvis issued,s of �sefall•emdoYContrep� subject[o worklman•s�ornpanss- <br /> Certifies the following:•'i dify tolat in the ped <br /> tion laws of California-" <br /> ate drawing nn revara^�filr' <br /> The apdic nt mus for all requir spcctio <br /> Tide:—f ---- Date: <br /> FwORR/JDE TMENT USE ONLY <br /> -.Oahe_ 'o Area <br /> K J <br /> Application Accepted by .Oats <br /> Date Final Inspemion by _ arm <br /> Pit or Grout Inspection by �q A �; lit nr <br /> i Additioral Comma"—nits, oc—� � I• •, 1>r�'a7r• v�: Arttc�i <br /> I 0 Stk. 466.8761 0 Lodi 3633621 0 Mantes BYJ-7104 O Tracy .. <br /> Applicant•Rerrm all copies to:Environmental Health Permit/Services 1601 E.Huehon Ave..P.O.Bog 2009.dt+c•.CA 96201 Gla, - <br /> s.t .. - •; <br /> �(r <br /> KfERWV NO. - <br /> t <br /> FEC AMOUNT DUE AMOUNT REMITTED GSH RECEIVED tlV GATE• -/ <br /> 1 INFO <br /> 3 .rH 1%24 taEV trey <br /> - EY.11•]6 - <br />