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�r APPLICATION FOR PERMIT <br /> -� <br /> i'•'E; , Ca� �C SAN JOAQUIN LOCAL HEALTH DISTRICT d f✓t <br /> 1601 E. HAZELTON AVE.,STOCKTON, CA R p o-1 <br /> Telephone(209)4668781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) NO <br /> App6cation 0 I irstry muds to the San Joaquin Local Heaton District for a Kilt to construct and/or instal the work heroin described.This application s <br /> matla in compliance with San Joaquin County Ordinance No.519 for aawege or No.1862 for well/pump and the Rules and Regulation of the San Joaquin <br /> Local Meelth District. �,1 6),A^ <br /> Job ArNrass ! '" }— <br /> City A1111 Lot Size x Z� PM <br /> Lfl Nla�rt Sa" g tj O �9u X532 <br /> Owners Noma n Address 7 y _ �/� Ph— <br /> Contractor`'�'1' Address L,c Ph.- <br /> TYPE OF WELL/PUMP: NEW WLLL❑ WELL REPLACEMENT❑ DESTRUCTION <br /> P/MP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 010 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation_ D...of Wall Casing n <br /> ❑Domesdc/Private ❑Gravel P,,-k ❑Tracy Type of Casing Specificaboris <br /> ❑Public ❑Other ❑Delta Depth of Grout Seal Type of Grout <br /> ❑Irrigation _1Lppmx.Depth ❑Eastem Surface Seel Installed by <br /> Repair Work Done C Type of Pump —n— M.P. State Work D <br /> Wall Destruction ❑ Wal Diameter Seating Materiel(top 50'1 0 e-}-Eti7„ r <br /> Depth Fdler Material(Bi—50'1 <br /> TYPE OF SEPTIC WORK- NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION❑ (No septic system permitted R public sewers ^ <br /> - avaitabb within 200 feet.l lYY) <br /> In st.iation wit serve: Residence_ Commercial_ Other <br /> Nurnber of fivrg units:_ Number of bedrooms <br /> Charoclar of soli to a depth of 3 teat: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments !, <br /> PKG.TREATMENT PLT.❑ Method of Disposal - <br /> - Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.6 Length of Ines Total bngth/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation_ Property Lina - <br /> O <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Wall Foundation Property Line <br /> .DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that dr•work will be done in accordance with San Joaquin county ordinances,state laws.,and 3 <br /> rub.and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed s0ern'.signature certifies the following:^i certify that in the perfomance of the work for which this permit is issued,1 shall not <br /> arrpby any person in such mariner as to bem <br /> came subject to workman's compensation laws of California."Contractors hiring or con <br /> subtracting signature <br /> cervfies the following:"1 certify that in the performance of the work for which this permit is issued,1 shall employ persona subject to workman's car pensa- <br /> ban,Isws of California." <br /> The applicant must call for ail r wired inspections.Complete drawing on reverse side. / y,�/ <br /> Signed - Tnb: W'�^s--tel Cate: C� -3Q—'`•�' — <br /> U FOR DEPARTMENT USE ONLY 4b <br /> Application Accapted by Data Area <br /> P-or Grote Inspection by Date Fal Irspecuon by �':'n}` Data <br /> ;ddnionsl Comments: <br /> ❑Stk 466-6781 ❑Lodi 3693621 ❑Manteca 823-7106 ❑Tracy 83543385 <br /> Applicant-Return ag copies to.Erwinonmerntel Health Permit/Services 1601 E.Huehon Ave.,P.O.Box 2009,Stk.,CA 95201 <br /> INW AM DU11T DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Q/�t 1 (• <br /> ER cera \ \\\ F`• <br /> c, f <br />