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t <br /> APPLICATION FOK 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 q <br /> (Complete in Triplicate) <br /> f <br /> ri Application is herby made to the Sen Joaquin Loral Health District for a permit to c+ratruct erM/pr kuGg the svcvk lutein tleacrlbad.This sppliutbrt✓s - <br /> :3 made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1882 for well/pump and the Risher and Regulations of the Sart Joaquin <br /> Local Health District. `yam <br /> Job Address / v'(nLC, �/.L(i YL-LILJ City ,[1,"LJ(�Lot Sin 34/ t-`S PM <br /> Owner's Name J Atldress -1p +� ��19Lf'hZ�,�LJJfC VY — S <br /> Contractor- (.�:}Address 51 _ n OGCElcense No. h2&_&j Phone6W-11 !J / <br /> TYPE OF WELL/PUM NEW WELL rWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK n 01 P. SEWER LINES _ DISPOSAL FLO.II_42jC PROP. LINE - <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PRS/SUMPS <br /> INTENDED USe TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� <br /> { 13 Incus; ❑Open Bottom ( Manteca Dia.of Well Excavation Ma.of Web Cal <br /> Domestic/Private 1Q Gravel Pack C 1 racy Type of Casing AVC, Specifications <br /> ❑ Public ❑ Other C Delta Depth of Grout Seal — .5?9 x Type of Gr <br /> C Irrigation --Approx. Depth Q_Eastftm Surface Seal Installed by- <br /> Repair Wolk Done ❑ Type of Pump Fff _ State Work Done /•l <br /> Well Destruction ❑ Well Diameter Seafng MateriaTthep.b0'I p <br /> Depth�� Filler Material(Below 501 j <br /> TYPE PTIC WORK: NEW INSTALLATION J REP41R/,4DOITION ❑ DESTRUCTION O (No em permim!8 public sewer is <br /> available wilhi i'PBC t.l <br /> I Installation will serve: ce_ Commercial_ Other <br /> �- Number of living units:._ Num held _ <br /> Character of soil to a depth of 3 feet:_ c Water table depth <br /> SEPTIC TANK C Type/Mlg \ Capacity_ No. Compartments 7 <br /> PKG.TREATMENT PLT,C �� Method of Disposal Ilio <br /> - Clarence to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of linos Total len3th/size- <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation Prope,Ty Line <br /> SEEPAGE FITS C Demh Size _ Number <br /> SUMPS ❑ Distance to nearest. Wali Foundation property U'w. <br /> DfSPC'3AL PONDS C _ <br /> 1 hereby certify that 1 hive prepared this application and that the work will be done in accordance with San Joaquil.county ordinances,state laws,and <br /> rules and regulations of the San JOi In Local Health District. <br /> Home ownar c.licensed agent's signature canities the following. "I certify that in the performance of the work for which this permit is issued,I shall not <br /> employ any parson in such mortar as to become subject to workman's atmpeasation law.of Callomia."Contractor's hiring or sub-contracting"natu•e <br /> canities the followin^-"i certify that in the performance of the work for which this permit is issued,I shall employ persona subject to workman's oanrM.ua- <br /> tion laws of California. <br /> The appli• n cast pall for all re red inspe/y�I'on's. CI,0 p_'e_t/%%e��/JJ.///ddd�]]towing ongrevverse.sic(e j <br /> Signed X + -GA __j_ arde�[.K�.cL'4 — Dale: <br /> FOID ARTMENT USF ONLY <br /> Application Accepted by / C < '���•�----- Date Area <br /> / ��`I 0 3., / <br /> Pit or Grout Inspection by J_1f�T�".L�('`'-Date-4,L_ 12 Fine; :nspactipn by_N/A Oeto <br /> Additional Com.unts: _ <br /> ❑ Sit. 466-6731 Lodi Xg-362' C Manteca 827-7101 C Tracy 8356185 <br /> Appi can!-Return all ccpies to: Environmental Health Permit/Services 1601 E. Natation Ave., P.O. Box 2009, Stk., CA 95201 <br /> F'F AMOUNTCOE T_.. <br /> INFO 1 AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMITNO. <br /> • EN 1..x Me u..l -7 1-7347 <br />