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F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.8781 <br /> PERMIT f:XPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPlication is hereby made to ince•L:ao Joaquin Lou'Health D'slre,for is permit to construct and/or install the work herein described.This appeeatlmt is <br /> -utde in compliance with San Jnagmn County Ordir,,,ce No.649 for aewegs pr No. 1662 for well/pump and the Rules and Regulations of the San Joapain <br /> ocal Health District. )),,//���� p� <br /> ' r �I V <br /> lob Address -L .]`'CL_ C' Lot She_ 47 PM <br /> Owner's N4 —Fs� La,.ti 1E_4LA,__ Address X11 Fit, <br /> Contran.U��„�_ �/} ddress j.� X IF 01 A=pa._T1 License N:4Fg1gr��S <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR O OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIOCATIONS <br /> Industrial Open Bottom ❑ Manteca Dia.of Well Excavation Die. of Wee Casing <br /> monastic/Private Gravel Pack ❑Tracy Type of Casing Specifications <br /> Public Other ❑ Delta Depth of Grout Seal _ Type of Grout �Gl <br /> tion --Approx. Do�p7th� 0 Entries Surface Saes Installed by <br /> Repair Work Done Type of Pump y_�,]_ M.P. L Q State Work <br /> Well Destruction Well Diameter Saskng Material(top 50'1 <br /> Depth ___ Fillef Materiel(Below 601 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U DESTRUCTION O INo septic system pwrtiIMA N Public sewer Y <br /> available within 200 Mt.) <br /> Installation will serve: Residence _._ Commercial_ Other <br /> Number of living units: ___ Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK ' Type'Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. " Method M Disposal <br /> Distance to nearest: Well Foundation Property Line �( <br /> LEACHING LINE No. 6 Length of lino Total lengthlute_ — <br /> FILTER BED Distance to eastern: Well Foundation__ Property Line <br /> SEEPAGE PITS Depth ..- She _ Number.___ <br /> SUMPS Distance to rroausl: Weil Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby cenify that I have prnparsel this application and that the work wBl be dorsa In accordance with San Joaquin county ordinances, state laws, and <br /> rulas and regulations rel the San Joaquin Local Health District. <br /> Hume owner or licensed agent's signature unifies the following: "I certify that M the performance of the work for which this Parrott is issued, I shall not <br /> employ any person m such manner as to troeome subject to workman's eomPenastlon Wya of California."Contractor's hiring or supeontraeting signature <br /> certifies the following: "I certify that in the pedormance of the work for which this purwt Is Issued,I shall employ parsons subject to workman's compenw. <br /> non laws offorms. <br /> The apdica Must call'for,allll.net ired n na. C ta drawing Ont r�rM rlda. C/��' /y7 <br /> Signed 1d 7(-ICLt'(�LL; �}- � Title: <br /> Op /G,/ Date <br /> 1 FOR DEPARTMENT USE ONLY <br /> Apdiutron accepted by __ �.'„�^�1 ._. __ Dau yy� <br /> Pit or Grout Inspecnon by Dau_._— FMN Inspection by I �.�_ Oats `T <br /> Additional Comments _ <br /> XStk 4646781 Lodi 369.3671 l:, Manteca S79-7104 n Tracy 8354MM <br /> Applicant - Return an cooler to Environmental HwNh Permit/Services 18D1 E. Harsiton Ave., P.O. Bos 2009, SM.. CA 95801 <br /> cK FEE AMO lf.T bUf AMOUNT REMITTED a REC,''VED BY DATE PERMIT-NO. <br /> INf0 -- CASH <br /> .. :'e rev . . t>C L � t1.7�\ � „1 ,'-1 - 31P--/` <br />