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''"r,ti• APPLICAT(ON FOR PERMIT #` 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEiTON AVE., STOCKTON, CA <br /> y Telephone 1209) 466-Ml <br /> ' PERMIT EXPIRES1 YEAR FROM DATE ISSUED t <br /> X6inplete in Triplicate) <br /> i <br /> Application is hereby made to the San Joaquin Local.Heahh DiWkg for a permit to construct and/or install the work herein deaatbed,This is <br /> made in compliance with San Joaquin County Ordinance W30 for sewage or No.IBM for"wall/pump&W the Rubs end RewArtione of the San Joaquin j <br /> Local Health District. t i <br /> ,G/aur ! / �� 9537 V erf <br /> Jeb Address _ ��r ACTHU„� C Lot Size PM <br /> Owner's Name • • Address ,s4�'_+¢• ” i s { -0 <br /> Contractor A4,C, hIth Address 3a4;Z 64 eh n 4 � License NA4 IS 30 RMone G7 -,�-6`f O I ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ + SYSTEM REPAIR El OTHER X/IO0 17-d F_VJEUL <br /> DISTANCE TO NEAREST: SEPTIC TANK 4� -SEWER LINES QQe-, I t � DISPOSAL FLD.�PROP. LINE 3OW l f <br /> FOUNDATION AGRICULTURE WELL.r =`�+ OTHER WE � PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n <br /> ❑ Industrial ❑Open Bottom ❑ Manteca pia.of Well Excavation—Q _ Die.of Well Casing Vt <br /> ❑ Domestic/Private '.-V Gravel Pad* '10 Tracy Type ofr' Fv[. Specifications <br /> ❑ Public ❑ Other ❑ Dena Depth of Grout Seat 24'n9"" Type of Grout ell7 <br /> ❑ Irrigation --Approx. Depth ❑ Easter Surface Seal Installed by 1-67 tj!C Work Done ❑ Type of Pump -,40jor— H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material(top 50'i <br /> Depth Filter Material(Balaw 50'1 <br /> OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ !No septic system permit pubiic sewer is <br /> (W� <br /> available within <br /> Installation tiw Residence_ Commercial— Other <br /> Number of Irving units. Number of bedrooms ' <br /> i <br /> Character of sod to a depth o t: <br /> --Water <br /> SEPTIC TANK ❑ Type/Mfg Ca No. Compartments j <br /> PKG. TREATMENT PLT.❑ Method of Oiaposal <br /> Distance t7r, rest: We Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length Tota(length/ ' F <br /> FILTER BED ❑ Dista a nearest: Well Foundation Property Lina <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMP 0 Distance to nearest: Well Foundation Property Line <br /> PKII;OSAL PONDS ❑ <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 end regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: -I certify that in the performance of the work for which this permit is issued, 1 shalt not F <br /> employ any person In such manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of alifomia." <br /> The applicant m t call for ail eq iced -n tions. Complete drawing on reverse side, fr <br /> Signed Title: t[ <br /> Date: <br /> C FOR DEPARTMENT USE ONLY —7 } <br /> Application Accepted by - p Data _ 17- Area <br /> Pit or Grout Inspection by ' to Fktiat Inspection by WA Data <br /> r / � <br /> Additional Comments: 1 5 G T'1?P/1 *` I r '/i t r t <br /> ❑ 5tk 466 6781 ❑ Lodi 369- 1 ❑ Manteca M7104 ❑ Tracy <br /> Applicant- Return alt copies to: Environmental Health PertHt/Services 1901 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNTDUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO H <br /> • Bt 13.24(REV.Iieef �� � - <br /> _ -- <br />