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APPLICATrON FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA yY <br /> Telephone "I 4654M1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (ConViete in Triplic ate) 7``,a <br /> District for a psm+h to cor mitt and/or,knatafa the work harsh daaesbd.Tlia app—'Jr <br /> Aypllcstion is hs sby made to the San Joaquin Loch Hwlth of the San Joaquin <br /> rtnada N nornpiatw a with Sart JOequkt County Ordinance No.549 for sewage or No.1862 for weN/pump and the Raba and Regulation <br /> Local Heakh Distric' <br /> r i+SAt:�Citi. ' <br /> Lot Size PM <br /> Job Add,assLC_ -- <br /> Owner's NameIP— PtJ//" Address _!sem �y aSrrZ F�EOEte <br /> � <br /> Address �*�� License No. PhOAe <br /> Contractor y, <br /> �y <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 <br /> OTHER 0 <br /> -PC1FiGPTNSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLO._.—PROP.LINE ' <br /> DISTANCE TO NEAREST: SEP'}C TANK S <br /> FOUNDATION _AGR!CL,.TURE WELL OTHER WELL PITS/BLIMP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Opal Bottom ❑Manteca .-... Die.of WellExcavation <br /> Div.of Wall C-11111 <br /> ❑Industrial SpeaPlicatiaw <br /> d C: y, J <br /> ❑ Domestic/Private ❑Gravel Pack ❑Tracy _- Type asi <br /> ❑Other O Doha Depth of Grout Ssai . ------ yps d Gran +' <br /> 0 Irrigation —Approx.Dept" ❑Eastern Surface Seat Installed by J� <br /> State Work Done <br /> Repair Work Done Type of Pump <br /> H.P. ';. <br /> Sealing Material(top 501 <br /> Well Destruct;on E: Alen Diameter F7er Maternal(Below Sin <br /> Depth public orN° is <br /> ESTRUCTION❑ p d <br /> IwSIALLf <br /> TYP£OF SEPTIC WORK <br /> Namlis.` <br /> knrtslierum <br /> ation wig s : Residence <br /> Commercial_ Other r <br /> Nwnber of bedrooms 31 <br /> Number of iving units: Water able depth �� K <br /> Character of sod to a depth of 3 feet: No.Compartments <br /> SEDTIC TANK ❑ Type/Mfg _ <br /> Method of D'rspoeN <br /> PKC.TREATMENT PLT.❑ _ Foundation Propen/line <br /> t Distance to nearest Well <br /> No.b Length of lines__�— L Total tength size- ,- <br /> LEACHING LINE Foundation Property Line m, <br /> FILTER BED ❑ Distance to rim~: Well ? <br /> s �--- Number <br /> ? SEEPAGE PITS Depth -z=----5� `r PropertyLi <br /> I Distencc 10 rna~: wall��f�— Foundation < <br /> SUMPS <br /> DISPOSAL PONOS r7 with San Joaqukn county ordi+arcs.auto 'srd <br /> I hereby certify that I have prepmed this appicar�n and that the work wig be done M accordance <br /> n rules and repulaSons d the San Joaqukn Local Health District. d the work la wtnicln thM Darrra is kosed.1 ahM rNA <br /> Horne owns►or licensed apetrt"s signature oarti—the following:"1 certify that In the lawsperfofrCalifornia.-ConVwwes nca <br /> employ any person in such mermen as to become subject to workman's wrrperwpertion laws of <br /> .tlraN a 0"persons or aEbtalunll 's dPEMwe <br /> cartifiaa the following:,•I certify that In the performance of.the work for vtfnich this permit <br /> I subject to Irrortcrrnen's cornpanw <br /> V,A Non taws of California.- on reverse aide- <br /> The appicant for ;sgtrked kgpectlom.Complete drswinC <br /> Dau: � <br /> e Tide: ej� <br /> i �►n} DEPARTMENT USE ONLY <br /> Ar°° <br /> �Accepted by OWN Date Final inapaction by � '� • <br /> Grout Inopection by <br /> J ✓ <br /> Additional Cotvment : <br /> Cl Stk 408.8781 O Loa 3a4 Sett O Maraca 823 7101 ❑Tracy 83&� <br /> • AGNlcant•Return <br /> all copies to: Environ <br /> rrntal Health Permit/Serums 1801 E.Hazelton Ave'.P.O.Box 2009.Stk..CA 86201 <br /> RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> Ew n}N eEv.,,ore, 769'o <br /> Ew n�M <br /> 1 <br /> t <br />