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• • APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE--TON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES_1 YEAR FROM DATE ISSUED <br /> r <br /> (Complete in Triplicatel 1 cation b <br /> Application is hereby made to the San Joaquin Loral Health District for a permit to construct and/or install the work herein described.This app <br /> made in compliance with San Joaquin County Ordinance No.$49 for sewage or No.1962 for well/pump and the Rules and Regulations of the Sen Joaquin <br /> Local Health District. ^^ .1/ r <br /> � CJ lV Ali Lot Sixe L !Ph. PM <br /> Job Address 1 c+,jO�,pyQ � � <br /> �. 1 _ Phone J <br /> i "Address <br /> r- Owur's Nam 11 / No. <br /> S/Oy <br /> --%% sA•A!�`�i,...� O Address7L7 License No..7�.82-=—Phone <br /> Contractrc DESTRUCTION ❑ <br /> TYPE OPS NEW WELL ❑ WELL REPLACEMENT ❑n OTHER 13PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ PROP, LINE _— <br /> SEWER LINES DISPOSAL FLD.�— <br /> {] DISTANJE TO NEAREST: SEPTIC TANK OTHER WELL— PITS/SUMPS O <br /> �—FOUNDATION AGRICULTURE -- <br /> WELL <br /> +t TYPE OF WELL PROBLEM AREA CONSTROCTION SPECIFICATIONS <br /> y INTENDED USE Dia.of Well Casing <br /> r 0 Industrial ❑Open Bottom ❑Manteca Oia.of Well Excavairon Specifications <br /> ❑ Drmrestic/Private CIGravel Pack L3 Tracy of Casing _ <br /> Tracy Depth of Grout Seal Type of Groat— — V <br /> I'1 Public <br /> 171 Other n Delta —_ <br /> I I litigation _Approx. Depen 1 I Eastern Sm!aca Saul Installed by <br /> fa of Pump H.P. State Work Done_.--�— <br /> WallRcpWork ion LJ Wall Sealing Material ROP 50'1 <br /> Wall Destruction ❑ Well Diameter piper Material IBelow'A'1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I aNailaDlpeiwnhfn 2001eetnied it public sewer la <br /> r <br /> Installation will serve: Rosi/dance ✓ Commercial— Other D / <br /> Number of living units: {— Number of ooms Water table depth�t <br /> Character of soil to a depth of 3 teat: �—_. Capacity No.Compartments <br /> SEPTIC TANK 01 Type/Mfg Method of Disposal <br /> PKG.TREATMENT PLT.❑ Distance to nearest: Well_ Foundation.12- Property Line <br /> ,51z—/ <br /> esa � Total length/size �• <br /> LEACHING LINE f No.&Length of lineaM Foundation ��• .Property Liu <br /> FILTER BED ❑ Distance to fourteen: Well_-{-sz=— <br /> yr <br /> Si:e Number <br /> SEEPAGE PITS Depth __ Foundation_LQ Property Line 7,5-- -- <br /> i_ SUMPS L1 Distance to nearest: Well /SQ <br /> DISPOSAL PONDS fl <br /> I hereby certify that I have prepared this application and that the work viii,ba cone in accordance with San Joaquin county ortlirances,stern laws,and <br /> rules and regulations of the San J9aquin Local Health District. pe <br /> Ree Home owner or licensed agent's si nature canities the following- I unify that l,ohn Iwvsoof Lalfornia.e Contractor'sihri hiring or AD-conuacting signature <br /> employ any person m such macer as to DOCOme subject to workman's amps rsons subject to workman's compenea <br /> t certifies the following:"I cenify that in the performance of the work:car which this permit is issued,I sell employ pe !e <br /> s: lion laws of California." <br /> The applicant mupt�all-or all rap/PiruQ inspe-• Ac�nQs. Complete Of, <br /> on reverse si OA:e: <br /> 6 61 e <br /> .� ask�\ �fK//•--- —Y— Title: V <br /> Signed X P <br /> FOR DEPARTMENT USE ONIY <br /> Date { � Area <br /> Application AccePnd by '� a / <br /> � /// - Final Inspection b� D�— <br /> q(t ok Grout fnspaetion by Gan <br /> `/ <br /> Additional Comments: <br /> ❑ Sik 4666761 ❑ Lodi 369-3621 ❑Manteca 8emice 6 ❑Tracy 836 <br /> Applicant- Return all copies to:Environmental Health Permit/Services lFgt E. Hazalion Ave.. <br /> P.O. Bow 2008, Stk.,CA 95201 <br /> CK a RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> fn tole <br />