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APPLICATION FOR PERMIT <br /> " 'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> •-x'1601 E. HAZEL T ON_-AVE., STOCKTON, CA <br /> Taiephone .(209) 466-6781 <br /> PERMIT EXP1}RES 7 XAAR FROM DATE ISSUED <br /> j­ {GoFnpleX& in.Triplicate) <br /> 4 Application is hereby made to'the San Joaquin Local Health District for a permit to construct and/or install the work herein described..This application is <br /> made in compliance with,San Joaquin County Ordinance No.549 for sewage-or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. t <br /> i Job Adcli6§s <br /> City C' ot Size <br /> PM <br /> Owner's Name L Address QUI Fr (I 1/ 472 Q <br /> ,_ Phone <br /> Contractor `; � R.�� <br /> Address c:,.etx.x 4' , <br /> Licei se No, PhaM �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL PL�4CEM T.. DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ - N, s13 `.. <br /> 5Y: TEM REPAIR ❑ E OTHER ❑ <br /> .DISTANCE f0 NEARES:T; SEPTIC TANK SEWER LiNE5 <br /> �- I��- DISIfOSAL FLD. PROP.`LINE <br /> r <br /> FOUNDATION ' AGRIdULTURE'WEL�� QTF+fR WELL PITS/SUMPS <br /> INTENDED USE. TYPEXQ WELL PROBLEM AREA �� <br /> R G,i NSTRUCTION SPECIFICATIONS <br /> s L7 Industrial, -❑ Open'Bottom ❑ Manteca Chia- of Well Excavation I <br /> " Dia. of Well Casing <br /> ❑ Domestic/Private, <br /> ❑ Gravel;Pack ❑ Trac <br /> f'l Public i7 Othet',r' y' a''Type of Casing <br /> Specifications <br /> Cl Delta Depth of Grout Seal <br /> 11'Irri anon Type-of Grout <br /> g Y �_ApprOx. Depth 1 1,Eastern . Surface Seal Installed by <br /> ti �, Repair Work-Dtme Type of Pump H. <br /> State Work Done_ <br /> Pt Wet),�e }ruction ❑ Well Diameter Sealing Material (top 50'I'. 4'•t �] <br /> r; _ DeptFii_.=�_„ Faller Material Welow 50') <br /> fr . TYPE OF'SEPTICFWORK: / NE aNSTALLAf1UN I:I REP.AlA/ADDITION DESTRUCTION I 1 {No <br /> septicsystem <br /> a r p- permitied if public sewer is ' <br /> available within 200 feet[)` <br /> Installation wdi server fij'sidence Commercial Other <br /> Number of liv i.W,ynits: -,r Numbieof bedrooms <br /> r Character of sor(tp a depthrof 3�fget:e <br /> + 'SEPTIC TANKf I i Water table depth.. <br /> � ❑;.,Type/Mfg s Ca acit <br /> PKG. TREATMENT.PLT. P Y No. Cpmpartments <br /> Method of':Disposal ` <br /> f Y Distance to nearest: INeH Foundation j <br /> rl+ r 3 F Property'Line <br /> LEACHING LINE ,No.r& Lentt'of lines <br /> °'' r TOO <br /> tal length/size <br /> a, FILTER BER _ <br /> . ❑ Distance t ne rest: Wel! _ Foundation �v,� <br /> k rf• —s�J�—__ Property.Line .� •. <br /> SEEPAGE PITS I I Dg tIfi ry' '7 f <br /> P Size Number <br /> r SUMPS ❑ Distance to nearest: Well <br /> u <br /> DISPOSAL PONDS Foundation Property Li ?o <br /> TT " Cl ., ne 5 l <br /> ` Lfierebyccertify that(have'pf-pparecl this application and that the work will be done in accordance with San Joaquin couniy'ordinances, state laws, and <br /> : rules and regulations of the San Joaquin Lo al Health(Sistrict. <br /> Home owner or licensed agent's signature cerifies the followin <br /> employ any person in such 9= "'I certify that in the performance of the work for which this permit is issued, I shall not <br /> manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contacting signature <br /> I, certifies the following; "I certjfy that in the pe'ormance of the work for which this permit is issued,I shall employ <br /> tipn laws of California." f ! p y persons subject to workman's compensa- <br /> The applicant must call for Zl'required inspections. Complete drawing on reverse side. <br />" Signed X r <br /> Title: <br /> Date: l <br /> •= OR D ARTNIENT,USE ONLY s=' <br /> Application Accepted by ll- <br /> *,, Date Area <br /> Pit or Grout Inspection by =' -r Date Final inspection b <br /> Additional ComDate;`. <br /> ❑ Stk 466-6781 i ❑;Yodi 369-3621 Y. <br /> r © Manteca 823-7304 ❑ Trac 835-6365 <br /> Applicant - Return alit copses to: E1lnvironmental'Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 <br /> INFOE,WMOUNT0UE AMOUNT REMITTED <br /> ` C RECEIVED 8Y r DATE PERMIT NO. <br /> +.EH.13.24(REV.r/H5y 1{ <br /> EN j14-28 IT'fp I �7�f <br /> 1 - e f 13 <br /> ti. 1. <br />