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04/03/2002 14 13 4640138 E.wJe-❑NMSgTAl- ]~EOL T H rAG2 01 <br /> IAPPLICATION FOR PERMIT <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E HAZELTON AVE, STOCKTON, CA <br /> Telephone (209) 456-6759 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tnplicatel <br /> Application a3 hereby made to the San Joaquin Loral Health oewmCt for a permit <br /> andlor r install and the work heroin Rules and ineg tdbe This <br /> Sona0Phc0b quur <br /> made in compliance with San Joaquin County Ordinance No 549 for wsarege w Na 7962 for wr <br /> Local Health DIEVICt <br /> I City Lot Sizc PM <br /> Job Address <br /> s Name Address -- Phone <br /> OwnerT <br /> Contractor,__ <br /> j��- dress )vLicense NO� ya_ <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL R&LACEMENT C) OESTpIJCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO MF-AREST SEPTIC TANK St_In►ER UNES DISPOSAL FLD- PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WEELL PITS/SUMPS `r s <br /> INTEImOED USE TYPE OF WELL PROuLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dig❑ Industrial y Q Open Bottom ❑ llllarra rteOra_ of Well ExcavationSpvcfffcvWn!3 <br /> a!Well Casrrrg <br /> �etifEcvtrpR9 <br /> O DOff*i tra/Pivv= ❑ Gravel Pack L Tracy Type of C=ng T of Grout <br /> ❑ Public C3 Other ❑ De6e Depth of Grout Seal Type. <br /> [I Imgatlon --APPmx Depth ❑ Eastem Surface Seal Installed by <br /> Repair Work Dans ❑ Type <br /> a! Puma HP State Work Dane <br /> Wats Destmcimn ❑ Wall Diameter ---- Sealing Material (top 5W) <br /> DepthMier Material (Below SWI <br /> TYPE OF SEPTIC WORK NarW INSTALLATION O REPAIR/ADDITION f'R' DESTRUCTION El (No=Ptrc avatom permitted ,t pubtrc sewer ss <br /> available within 2W feet) <br /> Installation vim serve Residence Other�— <br /> _ _ <br /> Number ofIlvmg unite Number of bedronrr,s Water table dept!, G <br /> Character of soil to a depth Of 3 teet f eZd d No Comparimertm <br /> SEPTIC TANK n Typa/Mfg Capatity� �a <br /> 1Vlethad of Dispasel 1 <br /> PKG TREATMFNT PLT Cl ��_ PrapertY Lina <br /> Distance to nearegr Wail Foundation <br /> Total length/stxe � <br /> LEACHING LINE ❑ No & Length of fines provsrtV lura <br /> FILTER BED ❑ Distance to nearest Well Foundation _ <br /> rte' Sit¢ Number <br /> SEEPAGE PITS X Depth —'2—--- _, PnN�eK1' line <br /> SUMPS ❑ Drararice to neane!IL Well Foundation <br /> I DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joequm Loral i-ieahh District <br /> Noma owner or licensed ggsM s signature certifies the tailawfng "I cert], that rn the perirrr+an� of the work for which trite permit 13 staved. I she no: <br /> laws at C <br /> employ any pe<�:n auch manner as to becpme subject to warkman's p comr=Wn aiifashail employ ooryons ublect a wrarkmart's cnmPrmsa' <br /> certifies the foliawing "I certify that in the portormance of ttw work for which this Damm is issued, <br /> tion lawn of ulfomia " side <br /> The aaptr4ant must rail for all required inspect!ans Complete drawing an rays �� <br /> Dato <br /> Signed X—azi�� --------- <br /> ppR DEPARTMENT USE: ONLY <br /> Date Area <br /> Appheation Accepted bV Date <br /> Date Fr�l I�pecbon by � <br /> Pit or Grotrx inspection by <br /> Adddwnaf Comment! g5-®SB <br /> ❑ Stec 466.67$1 Gl L r 3621 En Manteca 84-7104 ❑ Tracy 1 <br /> Applicant , Return all copies to Erwwwmentnl Health Permit/Servicas 1601 E h[ttxettbn Ave , P 0 Box 2009, 5tk. CA°. 0 <br /> KA RECEIVED 9Y DATI? PERfiATf No <br /> FEE AMOUNT DUE AMOUNT 9EMrrTED CASH <br /> . 5!t S3.�t iREy s�A st <br /> Em 1421 <br />