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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1901 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 120911 4968781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <br /> (Compbts in Triplicate) <br /> Application is hereby mads to the Son Joaquin Local Health District for a permit to construct and/or install the work heroin described.This application is <br /> made in compliance with San Joaquin County Ordinance No.646 for eswspe or No 1982 for well/pump and the Rules and Regulations of the San Joaquin <br /> a <br /> Local Health District. C <br /> Job Address 9 L• �d SCM i 1`� 'Igeo CftyA::Z14-�-'i:Z4 Lot Size Z'l��iS 101:f PM <br /> Owner's Nantas �!-E/7AA S Address 424L?jFffi l Sir o Af y. Pho, a <br /> Connectors Name /'A-L?��14��No. � � ^.5�4� Phorm <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s <br /> ❑ ITRIU601411 ❑Open Bottom O Monaco Die.of Wall Eltcavetion Dia.of Wal Casing <br /> O Domsadc/Privab O Gravel Pock O Tracy Type of Casing Specifications <br /> O Public ❑Other O Deka Depth of Grout Seal Type of Grout N <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seel Installed by t Y <br /> Repair Work Dons O Type of Pump H.P. State Work Done <br /> Wal Destruction ❑ Weal Diameter Seeing Material(top MY) <br /> Depth Flfier Material(Below 80) <br /> TYPE OF SEPTIC WORK: INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION (No septic system pemrtted If public sewer is f <br /> within 200 feet.) <br /> Installation will serve: Reeidsnca_ ComnterclM_ Ottw ) <br /> Number of living units: Number of bedrooms <br /> Character of sop to s depth of 3 fest•. Water table depth <br /> SEPTIC TANK O Type/Mfg Cspecity No. Compartments <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest Wal Foundation Property Lim <br /> LEACHING LINE ❑ No.6 Lmbgd of pries Total length/ <br /> FILTER BED ❑ Distance to nsivi Wap Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Sia Number <br /> SUMPS O Distance to Isaias: Wall Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify that I have propered this application and that tis work wig be done in ocmd nce with Son Joaquin county ordinances,state laws,and <br /> rules end regulations of the Son Joaquin Local Health District. <br /> Home owner or poerreed eg 11 drwture cartlllee the followMp:"I oeNfy that in the peAamence of the work for which this permit Is issued.1 shall not <br /> employ any person In such manner n WI ma &6isct to workme n's ooffgwmtion levee of CaMornis."Contractors hkhng a aub-contrscthp aignsturs <br /> coo I! the fopowkq:"1 oerlNy that in the perfomm+oe of tis walk for wluloh this pwff*le Issued.1 Nell employ person subject to workman's compermw <br /> tion laws of Callfonrle." <br /> Tt»dWcal for M required hop sadorno Complete drewMnp on reverse <br /> side. <br /> S*,odx C�LCJV�.D�- Cr .S{pc�oa - Title: 6 wN6,:2 Date: 2 ' z ig- 8 Se <br /> / MR DIB�AIITMfUYT USE ONLY ApplicationAoopbd by l raLt��-�-'�'�-� oat. Z _ Area G'� •�� ��/1 Q!!f <br /> Pit of Grout Inpeeft by Deb Final Inspection by Data <br /> Additional Comments: <br /> O Stk 40-Ml ❑ Lodi 3011-M1 ❑Mantece 823.7104 O Tracy 8366386 <br /> AppNcertt•Ratum al copies to: ErnkonnwvW Heald Pump/Servioss 19D1 E. Hizehon Ave.,P.O. Box 2006, Stk., CA 96201 <br /> FEE AMOUNTSU MOUNT NEW TTEDCASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH,sem IRW rorol 1 e o aL1 ws; <br /> EH/LA <br />