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S <br /> APPLICATION.FOR PERMIT + <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ 1 <br /> (Complete in Triplicate) <br /> i Application is hereby made to the San Joaquin Local Heafth District for to construct and/or install a pinstallthe work herein described.This application' made in Cornpiiance with San Joaquin County Ordinance Norm-549 for sewage No. 1862 for well/ is <br /> pump Health District pump and the Rules and Regulations of the San Joaquin <br /> Job Address 2 3 9l� Q �j� L t? �C <br /> — city Lot Size PM - <br /> Owner's Name _`� n �C1t �. /, As - Phone <br /> –.-T_-.� <br /> c� _ — <br /> Contractorti Address �= s l' "tl I aLicense No. hone kG <br /> TYPE OF WELL/PUMP: NEW WELL 3 "�WEL•L•REPLACEMENT G DESTRUCTION ❑ <br /> PUMP INSTALLATION 5 -t -•SVSTEM-REPAIR--C OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES 1 ;DISPOSAL FLD.___ PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL-, OTHER WELL __ PITS/SUMPS _ v� <br /> INTENDED-USE' -TYPE OF`VWILI,PROBL'EM-AREK'-!C6NS"QCMN S0E0.(FICATK)NS 1 <br /> O Industrial u Open Bottom r O>Manteca'1Dia- of WPI Excavations ?!� Dia. of Well Casing --- <br /> ..y. �. <br /> �11.DomestePrivate ❑Gravel Pack 0 Tracy Type of Casing_ SpecificationsPublic i ❑Otfiei " Depth of Grout�Sea1 ` Type of Grout <br /> `1 <br /> ,] Irrigationr~ l --APProx. Depth t] EastemN Surface Seal Instals bye <br /> T of Pump __ H.P. State Workone <br /> _D <br /> Repair Work Done L7 Type I t - <br /> ' Well Destruction i Well Diameter { _ Sealing Material It( 50')�� j ; <br /> Depth_— { `filer Matefial (Below 50'1 1 , sewer <br /> `` ed if pub('Ic Is <br /> I �` T,Y�E OFfSE\PTIC WORK�NEW INSTALLATION Ci REP tl/ADDITION DESTRUCTION Nava&a�tRle�,; �feet.) <br /> �.✓ i Commercial _ `Other <br /> tnstallatlon w 11 serve: Residence� I <br /> �- dumber'of bedrooms t { <br /> r--Number of living units: A I Water table depth <br /> Character of soil to a depth of 3 feet: l 2C?� No Cotirparvne^ts <br /> 53Method of Disposal <br /> p Type/Mfg :I!L '� �— � �- .` f l <br /> SEPTIC TANK '�j ! l Li <br /> \ <br /> PKG.TREATMENT PLT.O 1 "s -C � Foundation - Pr�'party <br /> ne <br /> Distance to nearest: Well <br /> oral length/size <br /> No. &&..gth of lines ' line — <br /> r LEp C ING LINE if ��- Property ' <br /> (=ILTER�BED C Dista'n'ce to nearest: WON_ r <br /> Sae_ --- ' Lie <br /> DeptNumber <br /> h _ t Foundation Property <br /> SEEPAGE PITS �pistance to newest: Well <br /> I SUMPS ordinances, state taws,and <br /> C _ in county <br /> DISPOSAL PONDS ---- , is id I stroll not <br /> that I have Pr��this appllcatat'a^d tflat work wnY done in accordance with San % or <br /> ormaitce of the work for which this permitntractirg signature <br /> CI he;and!r in Local!{eakh Distriu. 1 certify tliat in the�of Celiforrtra."Cpntrectar s hiring or sub co <br /> rules and'reifula�tions of'ttie�an signau re certifies tt�s following:' t to workman's compere <br /> Home owner or Incensed agents stgr►a subiect to workman's 00-00-"T� -y 1 shay employ persons sublet,K <br /> riner as t0__ 'srSSUed, ./',� CSA-. <br /> i employ any person nn such-Ma• prrttence of the work for which this Pe►n••j <br /> I cer4itythat.n mem ; ti } .r.{ J f 7't.•f) i,y ---�yy7.'� <br /> certifies Me following:" --t '�1" zYeVerse side. ✓(_ _ <br /> tion Www of Cat;ornia." ete'draN ing� <br /> The aPP t st�raN for all required rnsp�ot�. Comp( �l <br /> i _RRTMENT" -- ' <br /> I Signed. it_. R DEPA . �Y <br /> Area <br /> - -�--. , - at 7` <br /> , - __ _ Det. <br /> A cation 74ccepted by- c;�-_ .� <br /> _ Date___-�•=---Final lnspectron by <br /> Pit or Grout Inspection by "`- <br /> f C Tracy ti35 6395 1 <br /> C]Additional4 Comments: C Loi 3�. t ❑ Manteca gZ3-71041(;01 E. Hazelton Ave., P.O. Box 2008,Stk., CA 9620 <br /> ❑ Stk 46fr6791 Heehh Permit/Services <br /> Applicant- Return all copies to: EttVkOtt� � <br /> si <br /> ctc RECEIVED By <br /> DATE PEaMtT'NO. <br /> AMOUNT REMITTED CASH .ry, <br /> FEE ,_AMOUNT DUE - j, $ / <br /> INFO <br /> EH 1428 <br />