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APPLICATION FOR PERMIT <br /> SAN JOA.O.OIN LOCAL- HEALTH L)ISTRICT <br /> 1601 E. HAi EL ON AVE.. STOCKTON. CA <br /> Telephone 12091 466-5731 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �icornpme in Triplicate) This appncauon is <br /> :,ppiita hon is haiebv marle to the San Joaquin t_Ocal Heaitn Datum 1°r a Io cI for[anorer ins[an the warn herein uasttotsl. <br /> ,nada in crrnio�uinc�v°tri San Joauum u <br /> 1.uu nev u)in onto F:❑ `<;;i ler Sewa}te of hp. 1tiG2 for wrnf pumF ane Ina Hules ane NogwaUuns of ihU San Jnanunt <br /> i_otai Hcaun Gistnct. - r i PM <br /> CAY_ < f Lot SUO <br /> Jot)AddlesS --- - +` Phone ��•-�'�- <br /> i <br /> 11� Address �- <br /> Ownar s <br /> Name <br /> Ne. 'hone , <br /> Sf, AJdress DESTRUCTION LJ �rR g fj <br /> Con[rar.toi WELL VIiPLACEMENT CN <br /> tdEW WELL k�, iy OTHER U <br /> TYPE Of`NELLIPUf•7P' �" SY�TEM REPAIR it <br /> PUMP INSTALLATION €.1 DISPOSAL FLD_ PROP. LINE <br /> SEWER LINES _�-�-- PITSISUMPS - <br /> DISTANCE TO <br /> NEAREST. SEPTIC TANK -Y AGRICULTURE WELL OTHER WELL <br /> r i...7 i FOUNDA7'ON <br /> TYPE OF WELL PROBLEM ARTA CONSTR TION SPECIFICATIONS Dia.of Well Casing <br /> INTENDED USE �- Manteca pia.of Well Excavation <br /> Industti�t Open do+tom Specifications i <br /> - ,?Tracy type at Cas,h9 - �.... <br /> ",T Gravel Pack Type of Grnut�....� <br /> - <br /> Domestic lPnvate iDeka Dep[n of Grout Seal ---------�•^ .� _ <br /> '.: Public it Other ' <br /> Approx. Depth Eastern Surface Sial Inst aYlud by <br /> I litigation '— ppR P State Work Dona, <br /> `Report Work none'- L� Well of Pump --�� Sealing Material atop 50'1 <br /> Well Diameter �. <br /> Well Destruction Fillet Material IBelaw 50'1 <br /> Devin <br /> � wdi Is <br /> avadablo within 2P`J fce[.I <br /> 'Z TYPE OF SEF71C WOR%r NEW INSTALLATION I 1 REPAIRIAADITtON I 1 DESTRUCTION I I iNo sepac system p^,rmntetl d pubic sa <br /> 7 <br /> rn lnstallati°n wilt serve. Residence Commercial — Other <br /> ~j Number of bedrooms <br /> d Number of living units: Water table depth <br /> C A Character of Sod Capacisy�to a depth of 3(3 TypelNo.Comparmenis <br /> Mfg _� <br /> PTIC TANK Method of Disposal <br /> G.TREATMENT PLT.❑ Foundation 1�— Propcny Line <br /> r Distance to nearest: Well <br /> } Totall131191 size <br /> t C <br /> ACHING LINE LZ No.&length°f lines Foundation <br /> Property Lina��- <br /> �.{ ❑ Distance to nearest: 1Ve11 <br /> Z r FyLTER BED <br /> Size Number <br /> yEEPAGE PETS 11 Depth ��- Properri,thk <br /> Z Foundation—�— <br /> �UMPS Ll Distance to nearest. Well <br /> DISPOSAL PONDS [7 <br /> 3 I hereby sanity that I ileus prepared this apPlicatiart and that the work will be done in accordanw with San Joaquin county mdsnances,state Javr4.an <br /> -y rules and regulations of the San Joaquin Local Health District. nature <br /> 7 't certify that in the pert°rmance of the wank for which this Permit is issued.I a not <br /> nsation laws of California."Contrac[o s hisugatt to worof nkmartlng s compensa <br /> Noma owner or licensed agent's signature certifies the following: <br /> t Amptoy any person in such manner as to became sublet!to w°roman's hick <br /> candies the following:"I certify that in the pertormance of the work for which this permit is issued,l sftall employ persons <br /> tion laws of Cf Ii rnia,' <br /> The applica must Ggit for all required inspections. mple+e awing an reverse side. fir-, Date: - <br /> lit Tile: <br /> signed x <br /> r FOR DEPARTMENT USE ONLY ti0 r <br /> r Date <br /> Application Accepted by Date <br /> Date— Final Inspection by s <br /> Pit or Grout inspection by �« <br /> Additional Comments: ❑Manteca 023.7704 CJ ezocY <br /> fi36 i <br /> ❑ S ek 466-6781 ❑Lodi 369.3521 Stk.,CA 95MI <br /> Applicant•Return All copies to:Enviranmentat Reelect Par,ttitlServiee+16117 E.Hezehan Ave..P.O.Box <br /> T REMITTED RECEIVED By <br /> pATE PEflMlT NO- <br /> INFO - <br /> FEE AMOUNT DUE <br /> INFO llQ 1(?'2.aJIa[i-. <br /> .EN lI tREV,tin Si - <br /> EN 1415 <br />