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<br /> APPLICATION•.FOR,PERMIT
<br /> SAN JOAO,UIN@LOCQU�"EAtTH DISTRICT
<br /> 1601 E. HAZELTON,AVE., STOCKTON, CA
<br /> I Telephone {209) 466-fi781`
<br /> PERMIT EXPIR ,.l 7t`
<br /> ES 1 YEAR FRQIVI pT i$;?UE�
<br /> k. _ - is 13 l3 _ , ,�7.Ifie':�Co,_"�....K_„t ���.."1�J('...1�(S�rnt•.s .
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein"de&Ein6ddsThisrapplication is
<br /> made'in,:wrhpli@nce with;San-Joaquin,County,_Orclinence;Nq 648 fpr selNageaor No 1862 for veli/:pur}ip;�nd ihe,.Rules and�legulatior s',Qf the San cloaquin
<br /> Local Health District As } Lv
<br /> '.... Ifr, C ii,'r +k I,.,!"4 a {�i 1'P �'4Yryfz�e7 i ac 4,3[�z:t rrr-''.`s,��x'�, �(s �w t �,�E�t#✓c� I�tys �, C,oCi
<br /> r se•, C�SeAa°nI
<br /> ress :,�..
<br /> Job Add , 11., z . °otSizey , >, . "
<br /> Owner's Name _,__ �.:._r .: . -- Phone
<br /> I Contractors Name License No E" �S� f Ig i
<br /> I PE OF WELL/PUMP." NEW WELL!F-1 „r;WEL'L REPLACEMENT 111 ' DESTRUCTION ©hone i
<br /> a..
<br /> �e -- DISTlANCE'I
<br /> - - .- PUMP-INSTALLATION,--El .. -SY- S-TEM REPAIR ❑. 1
<br /> ,i ---O;#T
<br /> HER
<br /> TOiNEAREST. SEPTICTANK SEWER LINES DISPOSAL PROP LINE:
<br /> FOUNDATiON1 ;E
<br /> ..
<br /> _
<br /> i
<br /> AGRICULTURE WELL, iOTHER WELL . PITS/SUMPS i
<br /> USE TYPE t)F WELL PROBLEM AREA iV$
<br /> COTRUCTION SPECIFICATIONS
<br /> -- C•Industrial ----- .;.._. _Open+.Bottbm 0.-Manteca- .Diaiaof:Well.Excavation .; -_
<br /> o W _ „ ,Dia..of Well.Casing.'
<br /> Domesiic/Private ❑ Gravel Pack ❑ Trac ! ?: T "� '
<br /> Y Type of Casin $Peccations
<br /> ! ther❑ Public , ❑ O 4 - routSear lDept - Ty-p e of Grout !
<br /> `
<br /> fi _.
<br /> fl Irrigation- t• �Approx Depth--❑ Eastern Surface.Seal Installed b
<br /> Repair Work Done ❑ Type of Pump H P State Work Done
<br /> ;I
<br /> ❑ i Well Diameter Sealing Material (top 50')Well.Destructon FElk I {Bekow 50`)
<br /> TYPE OF SEPTIC WORK NEW INSTALLATION 13 REPAIR/ADDITION DESTRUCTION ( o septicsystem
<br /> permitted” '! "ifpublid sewer
<br /> is
<br /> 1
<br /> !�
<br /> ! ! , available within 200 feet)
<br /> 9 —Number ofEbedraoms -
<br /> Installation will serve !Residence Commercial Other }
<br /> Number of linin units:. __
<br /> t Chao racter of`soil ta-depth'af 3 feet+ ,.__-.._. ..�
<br /> f , , Water•table depth ' P -
<br /> _ ,SEPTIC TANKS !❑ TypedS- Y C acity YNo�Compartments
<br /> j.
<br /> !PKG TREATMENT PLT`❑ � E }
<br /> Method of Disposal `
<br /> distance to nearest Well Foundation' Property brie ' p
<br /> + -t I
<br /> NE ;No &Leri th olives t.
<br /> FLEACHING -I g i Notal length/size '-
<br /> i ..___FILTER BED ❑ bistance to nearest•-, all
<br /> i I Property`t ine -O
<br /> SC1 De th ,Number, r
<br /> SEEPAGE!PITS p Size ! ; - . l
<br /> SUMPS- I{7 Distance to nearest Well - Foundation '--trPropelty;Lknew-1 - = s
<br /> ,__..
<br /> DISPOSAL PONDS!
<br /> i❑ 1�-=- ! i
<br /> :1 hereby rules and rtif�4pa�ll ate $ray this application and that the work.will be done inEaccordance with Sanfloaquin,coun ordinances, statellaw% and: W '
<br /> prepared
<br /> i eg $ pain Local Health District I �
<br /> I Home owner or licensed `agent's signature certifies the following !I certify that in the performance of the work for which this rmit is issued ,I shall not`
<br /> - .-;employ any person-in-such•manner-as•to.becomesubject to,workman s;crorripensation laws.of-California."Contractor's hirirlg.or sub-contracting signature--
<br /> certifies tNe following I cert"Chet in the performance of the work for whicFi this permit is issued 1 shall em joy persons subject to workman's compensa- i
<br /> laws of-California = -. I
<br /> t SThe apply t must call f alLrequired inspections- Complete drawing on reverse side:
<br /> r A
<br /> ;Signed ! Trtle ' i Date- E
<br /> -�.._... _.
<br /> s I I i i FOR DEPARTMENT�USE'ONLY E
<br /> i Application Accepted by ! Date TD i Area
<br /> I 'Prt o�Grout Inspection bey _ �T Y 6� ! -fY - Date Fipal Inspection Yby ,
<br /> ! DeLe
<br /> i
<br /> 3 i j 1
<br /> ,Additional Comments. �_. . " i `____1i
<br /> ❑1 Stk 4668781 --G]-Lodi- 31g93B21-- --.CJ-Manteca'_.ffi3-7104 . -0TTracy-..83Fs
<br /> -- .. `i" i _ E. hkazeltgn Ave., P O Box 2009 Stk., CA 95201;
<br /> A licant Return all co les to: Environmental Health Permit/Servloes!1601 I
<br /> r...__ IE
<br /> .i .. +l AAAOUNT,REMITTED_" _ tiECE117E0 BY s" "154TEATNO�'_
<br /> i CA5H E132411iEV.10/831 �_ 3 �..._� � ! ; S � 4-Yk
<br /> �j 4'Srs! �
<br /> meg, i
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