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} <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 <br /> (Complete in Triplicate) <br /> Application:a hereby made to the San Joaquin Local Health District for a permit to construct and/or Install the work harm daseribW.This application is <br /> matte In compliance with San Joequnn County Ordinance No.649 for sawape or No.1862 for well/pump and the Ruin and Regulations of the San Joequi't <br /> Local Health District. (' <br /> Job Address SD 3o E� }= y City Sits PM <br /> Owner's NameLlcn/-G�— Address 45 421 +6 Phone73r^Q6� <br /> I <br /> Contnctcr'e Name��f �SV2,S 3�3 Phone�-�OO y <br /> License No. <br /> R , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ r^ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD, PROP, UNE v l <br /> a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> tl <br /> INTENDED USE TYPE OF WELL PROBLFM AREA, CONSTRUCTION SPECIFICATIONS d <br />■ ❑Industrial O Open Bottom O Manteca Dia.of Wall Exoavatlon Dia,of W14 Coft <br /> E O Don est*/PrNni O Gravel Pack ❑Tracy Type of Casing <br /> O Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 4 <br /> ❑ Irrigation ---Approx. Depth O Eastern Surface 8sM IrtataNad by <br /> Repair Work Dor.. O Type of Pump H.P. Stas Work Done <br /> WON Destruction O Well Diameter Sealing Material(top 60') L . <br /> Depth FNwr MatwW(Below 60') 1` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION OESTRU O (No septic sowsp�� N pubMo sewer w <br /> waNatila wMlln �J00 <br /> IroUktion WM serve: Residence>L- Commercial_ Ofhar <br /> Number of living units:-.L- Number of bedrooms -Zgt- F )`p <br /> Character of soli to a uOpth of 3 feet: &111 Water tabicN <br /> dpt►+ <br /> SEPTIC TANK O Type/Mfg _ Capacity No, te <br /> PKG.TREATMENT PLT.O Method of DIm <br /> r <br /> Dlstance to nearest: <br /> Well Foundation Prgrarty Lata <br /> LEACHING UNE ❑ No.8 Length of lines Total length/ela <br /> FILTER aED ❑ Distance to nearest: We" Foundation Propbrty Ling <br /> SEEPAGE PITS ' Depth + Sir Nurtnbsr <br /> SUMPS O Distance to nearest: Wall Za2;0 Foundation,��_ Property Lim <br /> DISPOSAL PONDS O 4 <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin 00t"y ortflnwnON.ibis laws,and <br /> i rules and regulat'ons of the San iosquin Local Health Clstrict. <br /> Horne owner or licensed agent's signature certifies rid following:"I certify that in the performance of the work for whicht this perm*In ktsnd,1 shed not <br /> employ any person In such manner as to become wblect to workman's compsrwtion laws of CaNfomis."Contractors hiring or sub-oormuft Upnelure <br /> aartifiaO the foNowkv:"I cm0y that in the P-rfomance of the work for which this pwn*Y Issued,I shell employ perum subject b worlanert a eattpetMa <br /> tion laws�Clwlfls."TM appoor a uIr d In ctiorrs. Complete drawingon reverse side, p '/ <br /> Signed - '- TItN: ��/ tr _ Dab: <br /> 5 <br /> r n FOR DEPART USE ONLY <br /> Application Accepted by v_ Dsts <br /> P*or Grout Inspection by a Date Final Inspsctlon by Dant <br /> Additional Comments: <br /> O Stk 485-Ml C1 Lodi 3t)B.W1 1-1 Manteca 623-7104 O Treoy 8354= <br /> Applicant• Return as copies to: Environmental Heatth Poind/Sorvkes 1801 E. Hetelton Ave., P.O. sox 20M, Stk.,CA 1=1 <br /> h _ <br />