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' <br /> APPLICATION FOR PERMIT� <br /> q y SAN JOAaUIN LOCAL HEALTH DISTRICT i <br /> 1$01 E. HAZEl.TON AVE., STOCKTON, CA <br /> Telephohe (20!91466-6781 <br /> LOCAL <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS ONNt� <br /> V\ (Complete in Triplicate) LNV1R �C14 <br /> cation ir <br /> Application is tmobY made to the San Joaquin LocalHea Health i rot fOf� a rNad Cord"e1�fort . pump sand t Rules endt 0 Rapu�t o of the Sanhersin described. This r Joaquin <br /> made in compliance with Sen Joaquin County Ordine re <br /> Local Health District. <br /> 16-06 Cily d Lot Size PM . <br /> Job Address Phone 916 Z 9 <br /> ,.,-� (�OrtJ AL7^ Address <br /> Owner's Norms <br /> Contractor �'r r- Addrers� � <br /> rtitcl i�Llcens' No.�q����Phone�Z-✓rf� <br /> NEW WELL WELL REPLACEMENT ©° 'DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR D OTHER D <br /> PUMP INSTALLATION ❑ PROP. LINE <br /> LINES � '_ DISPOSAL FLD.-. w <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER ? � PIT5/SUMPS <br /> FOl1NDATION AGRICULTURE WELL OTHER WELL __ <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA� l <br /> INTENDED USE _ _ . Dia, of Wall Catling <br /> p Industrial D Open bottom ❑ Manteca Dia. of Welt Excavation <br /> _ ` Type of Casing. PG ;M Specifications <br /> n Domestic/Private 1>;i iswal Pack U Tracy Type of Grout L" <br /> 1'1 public <br /> Cl Other (-I Delia Depth of Grout Seel I� k <br /> Sur{ace 5oa1 <br /> I 1 Irrigation .,_,_.Approx. Depth " I ( k-18tem Installed''w/y <br /> � State Work Dane <br /> U <br /> Repair Work Done Type — <br /> of Pump ��, H'P' O ! <br /> Well Destruction (7 Wall Diameter Sealing Material {top 501 <br /> Depth <br /> 04-' Faer Material (Below 60" J <br /> �Mpw.�o r1 <br /> TYPE Of SEPTIC WOftK; NEW fNSTAl.1ATI0N 1 I f11E1rAIWADDITION l l DESTRUCTION I l Svollablaiwithin�test.) al public sewer is <br /> i <br /> irnteMadon will aerw: Residence Carnmemial .._ Other_-.��--- <br /> Number of living units: Numher of bedrooms_. Wat �ispth <br /> Character of nail to a depth of 3 foot: <br /> No. pa <br /> Capacity <br /> oya q V" <br /> SEPTIC TANK ❑ Type/Mg ._____._�— Method Of 1 <br /> PKG. TREATMENT PLT, D Foundetinn. Property tine <br /> tance to nearest: Well - GCS <br /> Dis <br /> Length of tines Total Ili thlsize <br /> ❑ Na A Leng <br /> LEACHING LINE Foundation_! ��;CPcoporty L.kte r--�— <br /> FILTER BED C) Dielanca to nearest: Weil I <br /> Number <br /> SEEPAGE PITS I I Depth <br /> SUMPS L1 Distance to nearest: well <br /> Foundation_, i� — �Property Limb�^ <br /> DISPOSAL PONDS Ll <br /> I hereby certify that i have prepared this app)+�t►a+►and that the work will be done in accordenra vrith San Joaquin county ordinances. state taws, and <br /> rules and ragulationt of the San Joaquin Local Health Wktrict. I shell not <br /> Home owner or licestsad agent's signature o■rtifie■the following: "1 certify that in the parl <br /> pars of CaNfo+nia'�Co vaoctort hiring n sub-contracting signature <br /> employ any person in such manner as to become■ubiect to workman's eornpe t �ttMD"AeP8r1sa- <br /> certifies the following:"I certify thet in the parformenc of the work for which this permit is 7 <br /> tion )sari of Calitornie..1 I ENVIRONMENTAL HEALTH DIVISION <br /> The applicant mu■t Call for requi Ins . Complete drawing on reverea tide I; ct PE� C/ 7_dk f. <br /> CXR-'�__Z� <br /> Title: Date: <br /> Siwwwd <br /> _ FOR DEPARTMENT USE ONLY <br /> � Area <br /> pate, <br /> Application Aooepted by :F <br /> -Date._ Final Inspection bw p■te <br /> Pit or Grout lnepection by <br /> Additional Comments: <br /> [3 Stlt 4ffi4 81 ❑ Lodi NO-3621 ❑ Monte= 823.7104 D Tracy 83 , <br /> Applicant•Retum NI oopias to: E^vlr°n:'t°rAW N"tth Parn*/Sorvioet; 11801 E. Hamfton IAV*., P.I . B"3008. Stk..CA 65241 <br /> FEE aµplJNr Wr AMOUNT REMITTED H pecevriv WY DATE rutl�trt'nra, t <br /> INFO <br /> .CHItFtrIm.trast :55 , O <br /> r�V'j ik:i;Cr` <br /> �.r.i -.�Rs1.As'..- `.:i'=..�...ia.'i.a ri!"dL ,. I�:itr,.t":I".iL:; ,��•_��f.. <br />