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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 (209) 466.6781 <br /> PERMIT EXPIRE;; 1 YEAR FROM DATE ISSUED <br /> (Complete in Tr' <br /> Application Is hereby made to the San Joaquin local 1lealth District fora <br /> rade in comolianca with San Joaquin County Ordinance No.549 for sew " -tnzct end/o•'•Nt•r + <br />.ocal Health District. vurk herein described.This application is <br /> age or w- •or wall/Rvr.,:•,. •1; f Reguletkate of the San Joaquin <br />'ob Add•esa'•)-(,y/y s s <br /> fn/' . city�'L'�-'� '�- Lot Sin t�' PM <br /> lwner's Name_•� 1 <br /> Address �l� CC__ p <br /> h. <br />'ontractor's Name =� �` 7� <br /> License No, .. <br /> YPE OF WELL/PUMP: NEW WELL U _ Phone J <br /> PUMP INSTALLATION C WELL IIEPLACEMENT U DESTRUCTION ❑ <br />(STANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WEII. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA OTHER WELL PITS/SUMPS <br /> Industria] '------- CONSTRUCTION SPECIFICATIONS <br /> ❑O;,en Bottom U Manteca OT-f Well Excavation <br /> Domestic/Private ❑Gravel Pack0 TracDia,of WeWeillCS*V <br /> Public y Type of Casing _ <br /> ❑ Other C Delta❑ Type of Pump H.P. Depth of Grout Seat Type rout <br /> of <br /> ional <br /> Irrigation _„ppprox, Depth G _astern �• <br /> pair Work Done Surface Seal Installed by <br /> SII Destruction ❑ Well Diamoter State Work Done T <br /> Sealing Material(top 50') R <br /> Depth Filter Material(Be!ow 501 <br /> PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION U INo septic system <br /> istallation will serve: Residence Permitted if Public sewer is A. ' <br /> Commercial__ available within 200}est,) <br /> lumber of Irving units:_�____ Other <br /> Number o b rooms� � <br /> haracter of soil to a depth of 3 feet 3 t,t <br />'TIC TANK i?-,Type/Mfg — Water table depth <br /> i. TREATMENT PLT.C? �C-- Capacity- /S?.� <br /> No. Compartments O' <br /> Distance to nearest: Wel! Method of D' 1 <br /> Foundation ��_ PropWy Line �, <br /> CHING LINE La-"No. &Length of lines <br />-ER BEDTotal length/ <br /> G Distance to nearest: Well-"Q <br /> —1 Foundation�_ property Line <br />'AGE PITS +' <br /> ��Depth � - Size �/ r <br /> PS G Distance to neare•;t: Well { FNumber_'3 <br /> OSAL PONDS r oundation <br /> ❑ -{-�_ Property Lina_ <br /> iby certify that I have prepared this application and that the work will be done in accordance with San J <br /> and regulations of the San loaquin Local Health District. Joaquin county ordinances,able <br /> owner or licensed a lava,and <br /> gent's signature certifies the following: "I certify that in the performance of the work for which this <br /> np any person;n such manner as to become subject to workman's compensation laws of California."Contractor s hiring or wb contrscti <br /> 9v the feaowi permit h traced,I shall not <br /> ng:"I certify that in the performance of the work for which this permit is Issued,I shall signature <br /> ws of California.- ernploy persons subject to workman's company <br /> �pli:ant m call Wit{ <br /> �{ fired inspections. Complete drawing on reverse side. 4 <br />-1 X Lis <br /> v _ Title: _ ,OA)A)( L t- <br /> O F DEPARTMENT USE ONLY <br /> +cion Acreoted by ��� .c[ � <br /> 3rout Inspection by Area <br /> Final Inspection by <br /> nal Comments: <br /> Date <br /> 466-6781 89-3621 C Manteca 71 <br /> 2'Z M <br /> nt Lodi 3 <br /> - Ret+nn alt eo i.. Tracy 63ti83tf5 ?�...1'. <br /> COPi"to: Envtronmental Health Permit/ <br /> Serwc,-s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA M1 <br /> FEF AMOUNT DUE <br /> INFO AMOUNT REMIT'ED RECEIVED BY <br /> CASH DATE PERMIT'NO. <br /> O o <br /> � p <br /> Air, i <br />