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y�..r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> } Telephone (2209) 466.6781 <br /> I PERMIT EXPIRES 'I"YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Lola!Health District toy a permit to construct and install the work herein described,This application is <br /> mala in rampiiance with Sar.Joaquin County Ordinance No.549 for sewage or No, <br /> 1862 for wellipurnp and the Rules and Regulations of the San Joaquin <br /> Local health District. / <br /> Job Address .1 '�✓ � w _ lity PM <br /> +��__L Lot Size____— -- <br /> f <br /> Owner's Nana, <br /> _,_, 3y1,.� _,C�1� � Addrns5 .. .+ [�'! � L_ Phone <br /> �.. <br /> + - I <br /> — YC7 'tL �l r"..�.✓✓y'_bZ�!.sm�. Phone <br /> Contraclor License 7,. <br /> TYPE OF WELLIPUMP; NEW WELL Lj WELL REPLACEMENT L DESTRUCTION L- <br /> -. OTHER L] <br /> PUMP INSTALLATION 0 SYSTEM REPAIR D ? <br /> . <br /> DISTANCE TO NEAREST: SEPTIC TANK �.-..._._._. SEWER LINES .. <br /> _ DISPOSAL FLO._— PROP. LINE <br /> --- PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL ,—.OTHE1i WELLr <br /> INTENDED USE TYPE OF WELL PROBLEM AREA VONSTRUCTION SPECIFICATIONS <br /> Cl industrial L`J-Open Bottom Manteca Dia.of Well Excavation Dia. of Well asi+ <br /> Domestic/Private Gravel Pack Cl Tracy Typo of Casing .�_..� .,. _ ✓Sp�cificat ons � <br /> i'l Pttbk f Other !:-I Delta, ; Depth of Grout Seal Type of Grout <br /> litigation .:........,Approx, C!$plh� ! ! East/ �_•'"'Surface Saw installed by—­— .r----_ .._ ;. <br /> Repair Work Dane C:. Type of PumpState Work Done. <br /> .. N.P.. .—- , <br /> Well Destruction 17 well Diameter _ t_.�` .___ Sealing Material itop 501 '_F---�6.- - ------ <br /> Depzh filler Material Iseiow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATaON REPAiR;ADDITtON i i -DESTRUCTION 1 i iN, septi systdrn permal&d;t public sewers <br /> I ` i avai�af>te 1yithini200 teat.) <br /> Installation will serve: Residence.I Commercial— Other f <br /> Number of Irving unitsA 11 Nutr wr of bedrooms > i <br /> —� <br /> Character;of soil to a depth of,3 febt: "_" ,_r t t depth,,, -� <br /> SEPTIC TANK TtpeiMtsJ Y - .. Capacityl .. �floti'Comarttntrnts _.�rr^ _ <br /> PKG. TREATMENT PLT.17.1 <br /> dr <br /> ✓� Pr ' Lined <br /> i Distance to nearest: We11 _.. Foundation.._ t>prirt y <br /> LEACHING LINE � No.&Length of lines � T�otTalJrii3gtfitsi2e <br /> ��!'' Fewn3at4n'� �`_. — Property Line <br /> FILTER BED C-1, Distance to muwest: Well L_ — <br /> .f „- -- <br /> SEEPAGE PITS ` Depth Number <br /> ltote w <br /> w SUMPS L: Distance to nearest: /Weil._ Foundation __ PrapertY "w' <br /> DISPOSAL P040S f?i •✓ � ,:`� : L" <br /> i a ywr�ia n 4441in county ordinances,state laws, and <br /> I hereby certify t�iat I have prepared this application apdihat-the worm-will tie-tlanatin-a <br /> ? rules and tagulatiiihs of the San Joaquin Local Heaitfi Cfistrict. ».y�I L <br /> .,w...»,..-» <br /> iHorne owner or litensod agent's signaturte certifies ttie fallowing: "I cerfify't4 to the performance of die work for which this permit s issued. I shall not <br /> ` S employ any person in-such manner as to bocome subject to workmen's compensation laws of California."Contractor's hiring Of sub-cortuacting signature <br /> I certifies rho forfow ng:;,l cenify that in the perfarm`a'rioe of the work for whscl ,his permit is issu$d.1 shall employ persons subject trixkr <br /> wtnan's rompansa- <br /> tion <br /> aws of California:'" i <br /> 1 The applicant must call for all re ++ pectinr s. Complete drawing on reverse ai:!e. <br /> Date: "' - = <br /> t <br /> Signed X_._ Title <br /> i <br /> FOR, PARTM USE ONLY <br /> t Application Accepted by , = Date,_ <br /> 111 Pit of Graft inspection by Date Final inspection by <br /> AdditioviMl Comments: F <br /> Stk 466-V81 li Lodi 369.3621 0 Mordecai 823-7104 CI Tracy 835-MS <br /> Applicant• Return all copies to: Environmental Health PoarmitiServjc*a 1601 E. Hazelton Ava., P.O. Box 2009 Stk., CA 95201 l <br /> } FEE AMOUNT CTU£ AMOUNT REMITTER l.- ,f CIK.a < fiECEIV£R BV �'DSTE ?EAA917 N0 <br /> CASH- <br /> t,•. .[H t�asIREV.vxm �7 <br /> . EN lL1e. <br /> � 1 <br />