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APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1601 E. 14AZELTON AVE., STOCKTON, CA <br /> Telephone (2001 :66.67111 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cerrlplete in Triplicate) <br /> Application P.hotoby made to the San Joaquin Lora,Health D,stnct In,a pe,-.t ni gins,ntr.t and to,msra!l the work herein described.TMs application is <br /> mado in coniphnnre with San Joaquin County Ordin.rnce No.6,.19 for sewage or No IN,.for wr'n1p„mp and the Rules a-d Regulations of the San Joaquin <br /> Local Hoallh District. <br /> Job Address' WIC— p_lcl s. } (,/----------- '-tr��. :_:— lot Sire I AJC�1� PM <br /> Owner's Name/"N'_l.J���}7 �!_:. �-. A,ldreas <br /> Con lraftot LI t EfC{J IT.-��'...t 1� Jt 1"• ie /' _ I_'���.'®�:.�!'�_._.t_�c orae N,r �• (^l=5 <br /> r J. "as��/ Phone• <br /> TYPE OF WELL/PUMP: NEW WELL 1 WELL RLPLACL4trNT i. DESTRUCTION L1 <br /> — PUMP INSTALLATION Li SYSTEM REPAIR OTHER C1 <br /> DISTANCE TO NEAREST SEPTIC TANK SFV✓ER LINESDISPOSAL FID. PROP. LINE <br /> FOUNDATIONAGRICULTURE WFLL ..___ _. OTHER WEIL_.. PITS/SUMPS _— <br /> INTENDED_USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> Cl Industrial — L)Open 0oftom i 1 Manteca--_ Dia 01 Wen E*ca•.ahnn Dia.of Well Casing _ <br /> 1 1 Domeshc/Private CI Gravel Pack i l Tracy Tvps of Cas,np _—___--__— Specifications <br /> ('1 Aibht (7 Other I'Delta Depth of Grout Seal Typo of Grout <br /> I 1 Irtq(ahon -__Appro.. Depth I 1 Laslmn Surface Seal <br /> Rep-r Work Done O Type of po,epH P ____ _ State Work Done <br /> Well Destruction El Well Diarneler _,_--_--_ Seal-ng Aratenal ling,!41 <br /> • Depth----- __. ._.__ Feller Material IRe+ow rip l <br /> T YPL Of SEPTIC WORK. NIW It STAI IAIION I . III PAIR1ADDIT1Orf Ul TI+I If.T111N IKo septrC system permitted d pabht sewer is <br /> ava,lablo within 200 feet.) ' <br /> Installation wall serve: Residence t_._ Commercial AAAA.._ Other <br /> Number of living units:_- _ Number of tindrooms <br /> Character of sod to a depth of J feet:t: /'1^I l .1 J/1 �_--___ __ Water table depth <br /> SEPTIC TANK I,l Type/Mfg Canac�ty._. No.Compartments <br /> PKG. TREATMENT PLT.17 Method of Drspcsal <br /> Distance to nearest. Well Fotr­mt.o, .___.._. Property line— •.� <br /> IEACItING LINENo h lontph of tinesL�j_ '~gf_ _. Total le.111h1s..4.—_. _ <br /> FILTER Of D 1 I Distance to nearest. WellPropenyi•SEEPAGE PITSDepth <br /> SUMPC. I I Distance to nearest. Well.�/C'.-, F....... ono �;_. __. Property Line_-I ee- <br /> DISPOSAL PONDS 1 I <br /> I hereby corldy that 1 pave prepared IL a application and that the work wad be owe ,or .•tcoidance with San Joaquin county Ordinances,slate laws,and <br /> rules and tegulairuns of the San Joar n local health O?h,ct. <br /> Home owner or licensed agent's signahrrn certifies the lu4nw,ng. 'I cattily that it torr lierformanca of the work for which this permit is issued.I shall not <br /> emp'ay arty person in such manner as to become subpct to workman's compensabriq laws of California."Contracloe's hiring or sub contracting signature <br /> cerifies the following."I candy that in the Performance of the work for which this permit is issued.1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> t <br /> The applicant must call for all required inspections. Complain drawing on reverse side. r <br /> Signed li �r Tale: '_'r_L—a*-�-- Date ;C� r �" <br /> F,QR DEPARTMENT USE ONLY <br /> 1I .a <br /> lication Accepted by 1, 1' 1'� 1 Date 1-1 1 •r ll Area <br /> !' • ; � 1 <br /> `Pit Grout Inspection by 1 1 Data Final Inspection by�_�„_,•�_i , - �ri Oate 1. �, <br /> Additional Comments: / <br /> 0 Stk 466.6781 0 Lodi 369-3621k 0 Manteca 823.7164 0 Tracy 1135-6385 <br /> Applicant-Return all cope*to:Environmental Health Permit/Services 1601 E.Hazelton Ave.,P.O.Box 2009,Stk.,CA 95261 <br /> a <br /> INFO AMOUNT DUE AMOUNT REM111E0 CK® RECEIVED OY OATF PERMIT-NOFEE . <br /> __j <br /> . <br /> to-13 14 IREV.Tensok/ <br /> H 2a <br /> M - �1 �'�L.• f 1 -lid �('.j'Y-7.� <br /> 1 <br />