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41 y <br /> ti k <br /> APPLICATION FOR PERMIT <br /> qq: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {2091 466-6781 CON <br /> '.' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) z <br /> Application is neleby made to the San Joaquin Local Health District ter a permit to construct an.dfor instal: <br /> Local Health Dist `r:�work herein described,This application is <br /> made in comPhanco with San Joaquin Counry Ordinance No.549 for sewaga or No. 1062 for welllpump ant the Rules and Raguiarions of the San Joaquin • <br /> District. <br /> ZI 'Job Address/�✓'`>�!V. L V / ��--- � <br /> ,CisY/ �f Lr t Sixa+ �E`. -L PM <br /> # r rOwnar'syNa4 �L& 1 Address Phone <br /> �2(/dd . <br /> x Contracto ' Q Address1 �7�T7 G• %C7 <br /> ' L License flo..� Phone, <br /> ? TYPE OF WELL/PUMP; NEW WELL ❑ ` <br /> WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUfdP1NSTALLA7ION C) SYSTEM REPAIR Cl <br /> OTHER-❑ ;P <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER t.INES DISPOSAL FLO. PROP. LINE <br /> as u�Ftin?l FOUNDATION: AGRICULTURE WELL �— OTHER WELL _ PITS/SUMPS 5 <br /> t j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } <br /> �fG 4� °'17 Industrial'' 0 Open Bottom C Manteca Dia. of Well Excavation Dia.of Well Casing <br /> t " ' C,t R- <br /> 0 Domestic/Private Ll Gravel Pack 1..3 Tracy Type of Casing Specper <br /> yLY{ ✓' '`:i;. Y (' ..• <br /> ifi,:ations <br /> ?Public Fs�, <br /> I-1 Other f'7 Delta Depth of Grout Seat Type of Grout L <br /> 2t4.*ti '�yk <br /> '1;I Irrigation Approx. Depth I i Eastern - Surface Seal Installed by� r <br /> Repair Work Done 0 Type of Pump M.P. <br /> .' State Work Done <br /> Well uestruction C Well Diameter Seal'ng Material[top 50'I <br /> " . <br /> rt s " '` Depth Fidlr:r Material(Below 50') . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION R17F'AIG':A€ 0flTIptI i I DESTRUCTION I I INo septic system permitted it public sewer is ty!t <br /> 1 t tnstalatirn will serve: Residence '��� D e �` available within 200 feet.) <br /> .PlY - —_ Commer lal --� k <br /> Number of.living units: O• tr <br /> i rf f � Number of a nems <br /> Character of spit to a depth of 3 feat: - <br /> j ti SEPTIC.TANK, Type/Mfg <br /> � —Water,table depth <br /> Capacit �� <br /> Yom,xc -21 <br /> ` No. Compartmentsy,u <br /> 4 PKG TREATMENT PLT,C) <br /> r Method of Disposal <br /> Distance to nearest: Well � Foundation Property Line <br /> LEACHING LINE No. &Length of lines Total fenyth/site r' <br /> :FILTER BED ❑ Distance to nearest: Welt _ !' <br /> Frundalion _ Property Line <br /> A r r 'SEEPAGE PITS Depth Sixe 1�+r <br /> ra.'4`SUMPS. IX - `_-�.rs; Number <br /> Ll Distance to nearest: Weil Foundation ,14:'�_ Property Line <br /> DISPOSAL'PONDS n <br /> I hereby certify that 1 have prepa ed this appficatiin and that the work will be done in accordance withSan Joaquin county ordinances,state laws,and "w" <br /> +5} <br /> xa. 4,>• rules and regulations of the San Joaquin Local Health ptrict: <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the wurk for which this <br /> employ an• permit is issued, I shall not ;' <br /> r P y ) person in such manner as to become subject ro v.orkman's compensation laws of California."Contractor's hiring cr sub-contracting signature `r. I <br /> certifies the following:"I certify tr.;.t in;he partormance of the work for which this ermit is issued,I shat)employ k' <br /> `tion laws of California." P. p y persons subject to workman's,compensa 3 t <br /> j ; The applicant usI call pill r uired inspections. Complete drawing on rev orsp s da. y <br /> Signed <br /> _ Title: <br /> - FOR DEPARTMENT USE ONLY <br /> e;k r <br /> AP Ii by !_ - G� �j/� r� r <br /> EE d r 777 _ Date. Y [ _ Area' <br /> 3 rt r Grout lnspe!ion by <br /> 1 �� <br /> t mal Inspection by � <br /> ire Addrtionel Comm9nte: _ <br /> lrt ytXr <br /> . f '.o-t:]Still 466-6781 F ;] Lodi 369-,'1,621 ❑ Manteca a23-7104 ❑Tracy <br /> 835•b38$ <br /> �yt"e'i.�APpIK,�ni•,Return all espies to:Environ„�tentai Health Permit/Services 1501 E. Hazelton Ave., P.U. Box 2009, Stk., CA 95201 �'r' <br /> 41 <br /> FEE <br /> 9 -`�- <br /> AMQUNT DUE AMOUNT REMITTED LASH RECGVEQ By bA7E �,` �: f <br /> A�',.' 'INFO. PERMFT-N0, r •���9 <br /> EH 1124 IFTV.f/nyl ­7E04 14.25 <br /> z�'i�u.�.ag�'M1 uR T-t47i1 wt rR- 7 <br /> r <br />