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I APPLICATION FOR PERMIT
<br /> SAN JOAQW LOCAL`HEALTH DISTRICT
<br /> 9601 E. HAZELTON AVE., STOCKTON, CA
<br /> Telephone'(209) 466-6781
<br /> PERMIT EXPIRES1 YEAR FROM-DATE 1SSt f= ( "'""' ' `' " r
<br /> (Compfete'in Triplicate)
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instant he work herein described' This application is
<br /> made in compliance with San Joaquin County Ordinance No.549 for Sewage,or No. 1861 for well/pump and the Ryles and Regulations of the S
<br /> f Local Health District, E avr x
<br /> an Jo
<br /> aquin
<br /> Job Address ` 1 +i:,r� "•r.. Tra t t
<br /> • Jt„ ': w3 .. { -yi. ; ,Fi..144 �3city -h�l 3i- Lot_., fid+" �.P
<br /> Size
<br /> -- Owner's Namel, 6/'Ct�j.��21
<br /> ��_�Address-':'._
<br /> Phone''.
<br /> Contractor .: - _AAA— /Y License Noo`P-F_ e2
<br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACET L2MENPhone
<br /> DESTRUCTION ❑ #
<br /> C1_PUMP INSTALLATION ❑ SYSTEM-REPAIR .
<br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑
<br /> ���_ SEWER LINES �� DISPOSAL FLO. I
<br /> FOUNDATION.. PROP."LINE
<br /> AGRICULTURE WELL 9.
<br /> �-�4,. ~ _ TYRE OF WELL PROBLEM AREA" CONSTRUCTIONS OTHER WELL PTS
<br /> 'INTENDED USE' '��� -_" «". _ '-. I-' /SUi1IlPS
<br /> ❑ Industrial ` —� L PECiFICATIONS '`=b
<br /> ,., ,O~Open Bottom ❑ Manteca t x"
<br /> Dia, bf Well EXeavation 1 --.-...
<br /> ❑ Domestic/Private 1 Dia:",of Well Casiri `�": r
<br /> ❑ Gravel Pack ❑ Tracy 7 -
<br /> ❑ Public ' Ype of Casing Sx Z s }
<br /> El ❑ Delta "" 1' • ' 4Specifications }
<br /> 0
<br /> Irrigation ,� * 9 Depth of Grout Seal Q� �+ ti Ylti -
<br /> 9 --Approx. Depth ❑ Eastern i TYpe of out i 3�
<br /> RepairnWork Done ❑ _Type of Pump Surface Seal•"'Installed:by,``r
<br /> a a 5-1
<br /> Well Destruction''^�p
<br /> H.P' State Work Done A
<br /> ,4 Well_Diameter •• 'y ,
<br /> Sealing Material Itop 50'] A.
<br /> _ Depths Filler Material (Below 50')
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system pe mitted'if' u61ic r,'
<br /> installation will serve: Residence t P sewer is
<br /> available within 200 feet.) i
<br /> Commercial Other r
<br /> Number of livingunits: '
<br /> —�' Number of bedrooms__ `� •�� l
<br /> Character,of soil to a depth of 3 feet: k ° -
<br /> �SEPTfC TANK. 5 Type/Mfg �, Water table depth ,
<br /> PKG .TREATMENT'PL7. ❑ Capacity_ No. Compartments ~ ,
<br /> r � �
<br /> Method of Disposal '
<br /> A r.,ti Distance to nearest:, Well I Foundation -7---
<br /> � Property Line
<br /> LEACHING LINE ❑ No. & Length of lines
<br /> FiLTER BED ❑ I Total length/size
<br /> rest: Well Foundation i
<br /> Property,Line l
<br /> SEEPAGE PITS ❑ Depth
<br /> r , Size'
<br /> SUMPSumber j
<br /> r Cl❑i Distance to nearest: Well _„Wndation 'property Li r
<br /> +"DISPOSAL PONDS Q `;t �i� f
<br /> I hereby certify that I have prepared this application and that the work-will be done in accordarice'With San Joaqui o`unty ordinances, state laws, and
<br /> rules and regulations of the'San Joaquin Local Health District. ti , ��"
<br /> Home owner.or"licensed agents signature certifies the following: v
<br /> employ an 1 px �`''` '. .
<br /> P Y Y person in such manner as to become sub'ect to workman's omthe sat on laBv�isoof Califomiarf he is work fc, swork fort ringi or sub-contracting signature
<br /> certifies the person
<br /> Permit is issued, I shalt not
<br /> tion laws of Califor a.'I ce ify that in to performance Otho for which this permit is issued, I shall erripfoy persons ubject to workman's compensa
<br /> The applicant must call for%all <
<br /> quired.'nspections. Complete drawing on reverse side`.
<br /> Signed , ^—;...,. '.
<br /> _ -Title:
<br /> Date
<br /> k �i FOR D
<br /> EPARJpENTIUSE ONLY-
<br /> `Application Accepted"by ;/�"1>�✓�" ��^j`�
<br /> Date 7 Area
<br /> Pit,or Grout inspection by Date -�- y-- `:r
<br /> 4FInLInspection byAdditional Comments: D_ate❑.Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823 71 " 1
<br /> 94 y 835-6385 7 ,Z �•
<br /> Appncant Return all copies to: Environmental Health Permit/Services 1601 E. He Ave., p,p, Box 2009 Stk.,1CA 95201
<br /> s
<br /> AMOUNT-Dl1E`` '^ !
<br /> INFO 4M011NT REiidITTEfS"r ..e�,—'- -�-.e. -, �—,.� _,
<br /> CASH RECEIV D BYE DATE }PERMI7`NO."""7--
<br /> EH-13-24
<br /> -(REV.v/a57 •�.^...�- r .
<br /> EH 14.26 "� - ��- -,� .,,r,.-.a..-.,.r,,..,�.�,�,�`� `�.R 4 4 .-�++-�•�-.,��
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