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09/20/2004 10: 18 464013 ENVIRONMENTAL I .TH PAGE 01 <br /> x <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6791 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to the San Joaquin Local Health District far a permit to construct and/or Install the work hotel.described. This aoollcehnn is <br /> made In compliance with San Joaquin county Ordinancu No.548 for sewage or No 1862 rot well/bump and the Rulas and Regulations of the Sen Joaquin <br /> Local Health District '��Y�•a ..-r'I, �{, 'ToA�+ <br /> Job Address <br /> __ IPF/ / 5. Nrn _SW Chv�'c•.�— Lot Size PM <br /> _ ••F� <br /> •QD,E_ /4.�.t/ .. Address Jae'`—__^!,!�1r�'S Phone <br /> Owner's Name <br /> License No. Phone_ <br /> Conirzcl Or_ <br /> /(.(.(�[z1..IpPOdress_I�I.��►, 4 <br /> TYPE OF WELL/PUMP: NEW WELL Ifo WELL REPLACEMENT ❑ L..- <br /> PUMP INSTALLATION O, SYSTEM REPAIR f"1 OTHER Mt / <br /> O _ PROP. LINE SO <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLPITS/SUMPS (t 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL „v <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w '� <br /> _ n.. Gia. of Well Casing Q <br /> LI Industrial O Open Bottom U Manteca Die. of Well Excavatio Ci Specifications <br /> DC Domestic/Private I�FGravel Pack ❑ Tracy Type of Ceaing�v_ �,L7 _ <br /> f-1 Public f] Other <br /> fl Oahe Depth of Grout $eal Type of Grout <br /> I I Ligation —.Approx. [)split 1 I Eastern Surface Saul Installed by <br /> I Pump N.P. __ State Work Done _ <br /> Repair Work Done U TVpe 0 — ' <br /> Well Destruction ❑ Well Diameter Sealing Material (IOP 50'11 <br /> Depth Filler Material IBalow Sol <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I available witic hin 000 feetstem ) <br /> d public sfwpr H <br /> Inslalletion will serve: Residence _ Commercial , Other <br /> Number of living WPM _ Number of bedrooms Were( table depth <br /> Character of soil to a depth of 3 feet: _ __. -- -- ---- Tents <br /> SEPTIC TANK f7 Type/Mi '— _ spocal <br /> I of <br /> PKC. TREATMENT PLT. 171 Post-I1"Fax Note 7671 Da1p papas <br /> Distance To From <br /> LEACHING LINE O No. f1 Lt <br /> Co. epL Co. <br /> FILTER BED ❑ Distance phones Phonea <br /> FOx It Fax s <br /> SEEPAGE PITS 1 I Depth J _— <br /> SUMPS IJ Distancel <br /> DISPOSAL PONDS C:1stats laws, and <br /> I hereby comity Net I have prepared this application and that the work will be done in Accordance with San Joaquin county grdinancca. <br /> rule, and regulations of the San Joaquin Locei Health Oisiricl. <br /> ,joint c <br /> e owner on corned agent's signature eerlilies the lollowing. I certify that In the performance of the work for which this permit la iseuod. I shall not <br /> 1 shall employ perenns subject to workman's aamWtile <br /> employ any Parson m such me.ner as to become subject to workman's compensation laws of California." Contractor,s hiring M sub-contracting signature <br /> certifies the following:'1 cattily that in the performance of the work for which this permit Is Issued, <br /> tion Iowa of California.' 2 24 $8 <br /> The epplice mus ell for all required i specti s. Com late drawing reverse side. P`C Date: <br /> Title. <br /> Signed <br /> R DEPARTMENT USE ONLY <br /> � Dale Area �-- <br /> Application Accepted by Data <br /> lDate Final Iropoclion by <br /> Pit or Grout Inspection by <br /> Additlonal Comments: Manteca 823-7104 O Tucv 615-8385 95201 <br /> G Stk 466.6781 ❑ Lodi 365-3611 <br /> Applicant. Return all copies to: Environmental Health Psrmh/Services 1fY11 E. Hazelton Ave., P.O. Sox p009, Stk.. CA <br /> K RECEIVED BY DATE PERMIT'NO. <br /> FFE OUNT DUF AMOUNT REMITTED CASH n/1 W,,?79 <br /> INFO Q //� ✓t Y rti <br /> . FH fl-]a ItrFv. r e v S•(7� <br />