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001 <br /> 0 DO. yy. <br />�n Y _ 1 i A• _ �� — <br /> 1 <br /> APPLICATION FOR PERMIT `` C i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED \, <br /> (Complete in Triplicate) - <br /> AppIPAtion is hereby made to tt a San Joaquin L-mcal Hermlth District for a permit to construct and/or Install the work herafn dasedbed.TNs a(rptication Is <br /> mads in oomplfancs whh Sen Joaquin County Ordmance No,So for sewage or No.1882 for weWlpurnp and the Rules and Regulations of the San Joaquin <br /> Local Health District. ! ,ry <br /> Job Address ��`•.• -- WewT L/6z: ..,����City Lot Size PAA, <br /> Owners Name_ fZh!( __Address2D ZCtTEd&E7d}'�4/ Phone <br /> Contractor Addross License No. Phone r <br /> TYPE 0_F dVC-LL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTAUCTfON C] <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1�,Y110Air kjN$ 14),7L 1 <br /> DISTANCE TO NEAREST- SEPTIC TANK ^ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r/ <br /> ndusinal � ❑Open Bottom ❑Manteca D+a.of Well Excavation DIP.a Wag Caslnp � <br /> ❑Domestic/Private ❑Gravel Pack ❑Tracy Type of Cas! d _ Spec!llcatL ms <br /> ❑ Public ❑Other f_t Daae Depth of Grout Seat Type of Grout_ <br /> 0 Irrigation __Approx. Depth ❑ Eastem Surface Seal InstalleWby <br /> Repa'r Work Dane O Type of Pump H.P. State Work Done <br /> 3 Well Destruction ❑ Well Diameter Soong Material(top 5(y) <br /> Filler Material Ilaiow SO 1 <br /> '1 TYPE OF SEMIC WOPk:��NELL'INST TION0 REPAIR/ADDITION❑ Da STRUCTION❑ (No septic system permitted if public sewer is <br /> available within 200 feetJ <br /> Installation will sent Residence ___ Co arcml, Other <br /> Number of living units: Number of bodr s <br /> .j Character 04 soil.to a depth of 3 feet: Water table depth_ <br /> s SEPTIC TANK ❑ TVW/Mfg _Capacity No.Compantnemta <br /> PKG,TREATMENT PLT.❑ Method of DfNsasat <br /> Distance to nearest:, Wel! Foundation Property Lina <br /> { LEACHING.+LINE ❑ No.&Length of timer Total length/size <br /> FILTER BED EIDistance to nearest: Well Fou n Property Line <br /> SEEPAGE PITS ❑ Depth _Size Number <br /> SUMPS ❑ Distance to nearest: We!! Foundation - Property Line <br /> DISPOSAL PONDS- ._ -❑ __..... <br /> I hereby certify that I have prepared this application find that the work will be done in accordance with San Joaquin county ordinances,state krvs.WW <br /> rules and regulations of the San Joaquin Local Health Distr'.ct. <br /> t Home owner or licensed agent's signature certifies thii following:"I certify that in the performance of the work for which this permit is issued,I shall not <br /> employ any person in such manner as to become subj)ct to workman's convpanestion laws of California."Contractors hiring or sub-contfacting O;natum <br /> certifies the following-"1 certi the <br /> mit In the performanat of the work for whl:_h this permit Is Issued,I shall employ persons subjtct to vmkman's•compsnsa. <br /> Elk <br /> tion:laws of Cellfae." <br /> .. Tina applicant mwt cc el!required Ins Ions. Complete drawing on reverse side. <br /> Signed ,�,..r7Ftt[a: lr�C r {_hs�tSa,a Dan ' <br /> 5 <br /> c <br /> FO"EEAW ONLY t <br /> Ap catlon Accepted by Date — /lies , <br /> �. <br /> Ph or Grout Inapo by 1 Data A& Final Inspection 61+ Date46 <br /> r... <br /> r� Addltional Comment:: s4a <br /> ❑ 5tk 488®7f3L 0 L41 3&930fl Maniocs qW04 ❑Tracy W&M /f l' <br /> Applicant-Return all copies to: Environments!HeeftFi PemmitlServim 1901 E.Hazelton Ave.,P.O. Box 20179,Stk.,CA II 1 <br /> INFO AMOUNT DUE AMOUVT REMITTED RECUVED ONTE PERMIi'N0. <br /> 11 <br /> •EH 1}M Il7EV.»ee! <br /> EN tom ..��. O O <br /> e <br /> son= i <br /> i .. <br /> ti <br />