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� I <br /> f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209)466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pelt to construct and/or htstall alta waft hareirt daspibed.This Opp If Y71 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.IBM fpr went and the Rules and Rspubdons of the San Jasquin <br /> Local Health District. <br /> Job Address r City Site ' s PM <br /> Q-0 <br /> Owner's Name tlr'r v v Pftorte <br /> ContractorAddress_ V7� �Qt-ue+�"w' License No.q LP-Opi Phone tai I��7 <br /> t TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ; <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER'C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.LINE ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> € INTENDED USE TYPE OF V'1ELL }' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C�Industrial C1Open Bottom): ❑Manteca Dia.of Well Excavation Die.of weft Caning l <br /> G Domesticl Private ❑ Gravel Pack [3S Tracy Type of Casing peciftations ' <br /> ❑ Public ❑Other CI Delta Depth of Grout Seal Type of Grout <br /> Irrigation Approx. Depth ❑Eastern Surface Ssal Installed by <br /> Repair Work Done L.:, Type of Pump H.P. State Work Dome <br /> Well Destruction EL. Wall Diameter __^ 5ealing Material stop 90'1 t <br /> aFiller Material elow-Wi i <br /> t Depth <br /> TYPE OF SEPTIC WOrK: NEW INSTALLATION Q REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted 0 public sewer is <br /> available within 200 feet.) <br /> installation wilt serve: Residence— Commercial Other <br /> h Number of living units: Number of'bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth V ` <br /> SEPTIC TANK Q Type/Mfg Capacity No.Compartments <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to neamt: wen F Property Line f� <br /> / h/site <br /> LEACH! E Q No.&Length of lutes ` - <br /> LTER BED ❑ Distance to rears%: wen 2MAm <br /> ' Property Line <br /> SEEPAGE PITS ❑ Depth Si Number ti <br /> SUMPS ❑ Distance to nearest: well Foundation -- Property Line <br /> 1 / <br /> a DISPOSAL PONDS C7 - tt �yi <br /> t hereby sonify that f have"prepared this application and that the Worts will be done In accordance with San Joaquin.county ordinances.state fewa.and <br /> k rules and regulations of the San Joaquin Local Health District. <br /> Homs owner or licensed agent's signature certifies the following: ­I certify that in the performance of the work for which this pemlft Is isatred,1*on not <br /> employ any person in such manner es to become subject to workman's compensation laws of Csiifomis."Contractor's hiring or sub-contracting signature <br /> certifies the fonnwing:"I certify that in the performance of the work fo *Akh this permit is issued,I shall employ persons subject to workmen's competsa- 'k <br /> tion laws of California." <br /> The applnt must can ff in tions.Complete drawing on reverse sid-. 1° <br /> Title: Date .d <br /> FOR DEPARTMENT USE ONLY <br /> Apptti/on/n cept�ed tlV J Date �' ` Aro@ <br /> r .ri+dar-efoGt/Ynspottlo+raSr'W--1 Rare _�G^/final InspbCtbn py , <br /> Additional Comments: <br /> ❑ Stk 488.6781 ❑ Lodi 3W362t ❑Manteca 823.7101 ❑Tracy 8354M <br /> Applicant- Ran,:.&all copies to: Environmental Health Permit/Services 1901 E.Hazelton Ave., P.O. Box 2008.Silt.,CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED s RECEIVED BY DATE PERMIT No. " <br /> )NFO <br /> i, <br /> r-7 —^a <br /> a FM 1a?4(11ty •.l 1 t 1 C). t3t._ , 1� - 9 Q i `�1 <br /> - <br />