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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APP kAtxut»hereby made to the San Joaquin Local Health District for a permit to ronstruct and/or install the work herein dew <br /> ribed•Tlrs application is <br /> made M compYance with San Joaquin County Orde„arice No.648 for sewage or No. 1862 for well/pump and the Rulas and Regulations of the San Joaquin <br /> Local Health Urainct. <br /> Job Address q�Z Z /�'r��.ST City ry <br /> � <br /> �� T (( 44 D Sze_ — PM <br /> Owner's Name ill_ •�-�d wdfL i Address .. L� L.( <br /> Phone <br /> Contractor � _.._ _ Address h�/3�X...1��'�'._ ..3?Gcensc No. <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTIUN <br /> ~— PUMP INSTALLATION ✓ SYSTEM REPAIR CI OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK..�(i�_+ SEWER LINES _ DISPOSAL FLD.. PROP. LINE <br /> — FOUNDATION __--__--_—_ AGRICULTURE WELT —___— OTHER WELL___ PITS/SUMPS 4 , <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC_IFICATI 1� <br /> Industrial L Open Bonom 17 Manteca Dia.of Wall Excavation _ <br /> n /'f1/ Dis. of Woo c..g 6omestx:/Pnvra irt;awi Pack i:)Tracy Type of Casing__- J✓�G/, 160 Specifications <br /> Public i.;Other L1 Datta Depth of Grout Seal <br /> -- Type or Grout <br /> Irrigation / _Jtpprox. Depth i.; stern Surfa Seal Installed by <br /> Repair Work Done 3i/ Type of Pump _�� H.P. _.__ _ --I--__-.__ State Work Done <br /> AUMLhilkill (A 69 1C_ <br /> Well Destruction a/ Well Diameter a <br /> Seating Material(top 501 <br /> Depth _ Filler Materiel 18elow 60') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i-i hEPAIR/ADDITION I I DESTRUCTION i l (No septic system permitted ifblit <br /> pis sewer is <br /> Installation will serve. m <br /> rvs. Residence__- Comerciol _ Other evadable within 200 fest.) <br /> Number of living unr+,: Number of bedrooms ._ <br /> Character of sod to a depth of 3 feet: _-- Water table depth <br /> SEPTIC TANK i. T /A;1 _- ._ Capac <br /> YW g __— - -----_-- No. Compartments <br /> PKG TREATMENT PLT. <br /> Method of Disposal _ <br /> Distance to nearest: Well _ Foundation . ..__ Property Line <br /> -- ---------------- <br /> LEACHING UNE No. 8 Length of Total length/size <br /> FILTER BED Distance Barest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Sue ---_ _.- -Number <br /> SUMPS Distance to nearest: Well ___ Foundation _ Property Line <br /> DISPOSAL POtfbS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,and <br /> rules and reguI the San Joaquin Local Aealth District. <br /> Home own or licensed a nt's signature certifies the l�"- <br /> g: "I certify that in the performance of the work for which this perrrut is issued, I shall not <br /> employ a person in such nner as to become subiew rkman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies a following: "I cert/ hat in the r1 rm n h workfor which this rmd is issued,I shall employ persons subject to workman's compensa- <br /> uon la of California.•• <br /> The ap licant or I require in ti o ete dr, a side. <br /> Signed <br /> l <br /> — /� - ^yam{_ Date: <br /> tie vv <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by` `_-- -.___ Date _ _ <br /> Y �l�rea <br /> Pd or Grout Inspection by ��P/r � Oate ?Final Inspection b \ - `l <br /> bate <br /> i <br /> l I },'c .ft <br /> Addnional Comments: �Y_-t ui 1 u ��--fu � � (11- �-ti4�•} y�� �_<_< � �f� <br /> s- ai i l <br /> Stk 466 6781 Lodi 369 3621 Manteca 823 7104 1 )Tracy 835-6385 ` ��/ Pi.+ C <br /> Applicant Return ad copies to: Environmental Health PermiUServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 tl J <br /> FEE CASH <br /> AMOUNT DUE AMOUNT REMITTED CKs RECEIVED BY DATE PERMIT NO <br /> NFO <br />