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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELITON AVE., STOC ­ <br /> KTON, CA <br /> Telephone (2091 466-8781 <br /> PERMIT EXPIRES 1'.YEAR FROM DATE ISSUED ' <br /> (C0.MPj8t8jrTriplicate). <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work heroin deacdbad.This application is <br /> It —do irreamplionoe with San Joaquin County Ordinance No.5"foruwage or Na-7812 for11/pump and the <br /> Local Health District. .0 Rules andRegulationgi of the Son Joaquin <br /> Job Address <br /> Azi,T-AD 4,V1 <br /> Cftyrxe <br /> 4LAa�plvl <br /> Owner's Name <br /> Phone a Y <br /> C -------- <br /> tractor's Name <br /> TYPE OF WELL! UMP: NEW WELL go- WELL REPLACEMENT Ph a <br /> DESTRUCTION U <br /> PUMP INSTALLATION -,"AYSTEMI REPAIR Ll OTHER Li <br /> DISTANCE TO NEAREST: SEPTIC TANK -jr7p.6 <br /> SEWER LINES DISPOSAI:FLD C-) PROP. LINE-_Z&�; <br /> FOUNDATION AGRICULTURE WELL'— OTHER WELL' •� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF;CA--nONS <br /> ZAWO-Bottom- <br /> Lj Manteca Dia.of V ed t Exciiv& Dip.of *Ii �k <br /> �^[pb�ittastlt/Private ,,ki Casing_ <br /> 0 Gravel Pack [:I TW. <br /> Type of �Spscificadona <br /> 0 �ubllc; 0 Other L1 Delta Depth�rf�Grout Seal Type of Grout <br /> Irrigation <br /> __Approx. Depth Cl Famarn Surface Seal Installed by. .!t41L <br /> Repair Work Dorm 0 Type of Pump <br /> H.P. Sum Work Done -X <br /> Wall Destruction 0 Well D, <br /> dome Seokhg Material(top EW) <br /> Depth !!!i`4 'r <br /> -Filter Material(Below w) <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION 0 REPAIR/ADDMON❑11 DESTRUCTION <br /> 0 (No septic System permitted if public sewer is <br /> Installation will serve: Residence Commercial Other <br /> -Number of riving units: <br /> Number of bedroorns <br /> Characterof soil to a depth of 3 feet, S,I <br /> TANK —Water table depth <br /> SEPTIC <br /> CepacrtY No. Compartments <br /> PKG.TREATMENT PLT�-o <br /> Method of Disposal <br /> Distince to nearest; Wall Foundation <br /> Property Una <br /> LEACHING LINE <br /> 0 No.1b Length of lines <br /> 4 Toil le h/ <br /> FILTER BED 11 Distance to nearest: :Well Foundation i Property Line <br /> ri <br /> _3 <br /> SEEPAGE PITS 0 Depth 4 '. . . .. <br /> -Sig@ - Number <br /> SUMPS <br /> 0 Obtince to nearest: WellFoundation Property Una <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared thle application and that the work will Fbe done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin Local Health District:- <br /> Home Owner of licefised agenea*j4wje cartifies.the I ti I shVI not <br /> employ any person In such manner as to become subject to workman's compensation taws of djkffomj8.­Coftwtor's hiring or Sub-contracting signature <br /> cerdfies this person In <br /> 1,08dify that In the performance of the work for which this permit is is� <br /> tion laws of Califorrila.- I shall employ p6mons subject to workmen's corripensa- <br /> The.applicant must call for all jksd spectl Complete drawing.on re'v'u'roe's"kia. 4 <br /> MZ.=' , \_z . <br /> Signed.- Two; 7 <br /> Daft. <br /> FOR DEPARTMENT USE ONLY <br /> Application Ac.cap ted by -0 Data <br /> Pit 1(f, <br /> Inspection by al Inspection by <br /> Data <br /> Additional Comments! <br /> L'7 Stk 460-678i 0 Lodi 38%a621 0 Monte 1 <br /> ©Tracy 835- 6 <br /> A�pllcant-Remm all copies to. Environmental Health PerrFI823-7104/Semieft le0l E. Hazedton Ave. <br /> P.O. Box 2MG,.Stk., CA 9=1 <br /> r -rFEE. F <br /> INFO AM DUE AMOUNT REMIT`rED Reciavid By- <br /> CASH DATE PERMfT"WO.' <br /> 9H 1344 4FIEV.110/M <br /> �H W25 L7 1- (us"00-- LI-R' 4 -7$ 0 <br />