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- APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;. (Complete in Triplicate) application is t <br /> ce No.549 far forager No. 1862 for we <br /> and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin LocalHealthDistrict for a permit to construct and/or install the work herein described.This app f <br /> p <br /> made in compliance with San Joaquin Couty , <br /> Local Health District. PM I <br /> - City of size <br /> Job Address _ 9 <br /> Phone <br /> L -- Address —z 1 : <br /> Owner's Name r S y3, <br /> Phone 1 <br /> llilns�d�Lls? 5 1/1/ ense No. <br /> Contractor's Name WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f NEW WELL ❑ OTHER ❑ ` <br /> TYPE OF WELL/PUMP: STEM REPAIR ❑ <br /> PUMP INSTALLATION �R�P,ir�c��FN DISPOSAL FLD. PROP. LINE <br /> SEWER LINES 1��_--- �---k- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK _--� AGRICULTURE WE <br /> OTHER WELL <br /> FOUNDATION ��� <br /> INTENDED USE TYPE OF WELL PROBL� CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Manteca D-ia. of Well Excavation .�❑ ❑ Open Bottom Specifications <br /> industrial <br /> ❑ Tracy Type of Casing <br /> ` Domestic/Private E3 Gravel Pack Type of Grout <br /> i C1 Other ❑ Delta Depth of Grout Seal <br /> ❑ Public Seal eal Installed by S <br /> �grox <br /> Qp . Depth ID ai,i � hi 17 �L7L�'�9U <br /> ❑ Irrigation epH P f State Work Done <br /> Repair Work Done ❑ Type of Pump —Tito— <br /> I {top 501 <br /> Well Diameter Sealing Materia <br /> Well Destruction ❑ I Filler Material (Below 50'} <br /> Depth UCTION ❑ (No septic system permitted <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAlR1ADDITION ❑ DESTRif public sewer is <br /> ��---W-- -�-Treii ""- 4 Commercial— Other l— <br /> Installation will serve: Residence <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to:;~ddepth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK �❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.,❑ Foundation Property Line�— <br /> Distance to nearest: Well �— <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Line <br /> .� Property <br /> { FILTER BED EIDistance to nearest: Well <br /> Size Aid I Number <br /> SEEPAGE PITS <br /> JD Depth j Property Line-r-� <br /> ^^ Foundation <br /> SUMPS t ... Distance-to nearest: Well : <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby certify that i have prepared this application and-that-the-work-will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's sig <br /> as tos ail not <br /> rbecome subject following: <br /> wiorkman'srcomperisa;ion fawsoof California.- Contractor's hieing singe permit tub-co ntractnclompeansa- <br /> 1 employ any person in such manner <br /> certifies the following."I certify that in the performance Of the work for wh9ch this permit is issued,I shall employ pe <br /> tion laws of California." 1 9! F <br /> '�t� <br /> c� , <br /> The applicant st X11 or all fired inspections. Complete drawing $n reverse si10 <br /> _ Date: <br /> Signed t04s r) <br /> FOR DEPART NT�U$E ONLY <br /> Area <br /> v ' Date _ <br /> Application Accepted by /r�J <br /> Date <br /> Date Final Inspection by .-w---- <br /> Pit or Grout Inspection by --r -s--"""" <br /> Additional Comments: ❑ Manteca 823 7104 ❑ Tracy 835-6385 <br /> C1Stk 466-Mi ❑ Lodi 369 3621 <br /> - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sty_ , <br /> j <br /> Applicant <br /> --------------- CK*, °\RECEIVED By DATE PERMIT'NO. / <br /> FEE AMOUNT DUE AMOUNT REMITTED ,` GASH 'J ` y// <br /> INFO <br /> +EH 13-L41REV.10183) S. p d •^s --. ,"., - <br />