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r I <br /> APPLICATION FOR PrRNA IT <br /> SAPf JOAC4UiNi LOCAL HEALTH DISTRICT <br /> 10,01 E. IIAZE'.TON AVE.., STOCKTON, CA <br /> Te:lephonu (209) 4GG-6781 <br /> _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> W[CDmplele M Trilsllca[cl <br /> the San Joaquin Local Health D-strict for a, yid 10 construct andlor install the wort herein tlescribns This applicationoaqs <br /> Application is hereby Drd.nance No.547 lur sawagu ur No. IF&2 lot w.I1jpun1p and gild Ru <br /> and Rallulatiao1 the San jnaqum <br /> made to <br /> made in compliance wilt,.,an Joaquin County <br /> Local Heallh District. <br /> �• �il �a3 _ C,ty Los Sire..__� PM.�..---• <br /> Job Address <br /> �oA _ Phone 1J� <br /> ^� ~ _ Address r_�] - ~S71--- -- -� <br /> Owner's Name ��L_,,�,� � <br /> n S�TcC License NoCS--- l-'� p <br /> -� <br /> -1 cy,crw�+ ' <br /> NEW WELL�?Q WELL REPLAE <br /> CEMENT fa DtQ1 L <br /> TYPE OF WELLlPUMP: SYSTEM REPAIR CI 2IF EI; <br /> DISTANCE TO NE ] `Jg <br /> PUMP[NSTALLATION U PROP.LIN <br /> AREST: SEPTIC TAN <br /> Kt:� SEWER LINES DISPj' . PITS/SUMPS <br /> OTHE /ELL <br /> FOUNDATIDN �- AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAII N o 0 Casing �-t <br /> 1 — old Dia. at Wcll E.cavatron p <br /> lU Open Bottom C7 Manteca G :Groul <br /> I I lnduslrial 0 Trac Type of CasingI I Domestic1plivafe /"Gravel Pack y �� Type of1'1 Other f"1 DeltaDepth of Grout Seal <br /> -Approrr, Depth t I Esstatn Surlaca Seal Installed by _ <br /> I I Lntlauun -- Slate Work Done,- <br /> RHv pair Work Done <br /> Type of Pump H.P. <br /> Well Destruction <br /> [.l Well Diameter Sealing Material Ilup 50'I -� <br /> Depth Filler Material 1 DE50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t f HEPAIAlADDlTION k I DESTRUCTION I I ."allots atlwhhln 206 feel-)red i!public srwer is <br /> Installation will serre: Residence— Commercial_ Other - <br /> Number of living units: Number of bedrooms Water table depth— <br /> Character at soil to a depth of 3 feel: Capacily� No.Compartrnems -- <br /> SEPTIC TANK n Type'Mig Method of Disposal <br /> PKG.TREATMENT PLT.Cl Foundation Property Line <br /> Distance to nearest: Well <br /> --' Tatallerrgthlsire <br /> LEACHING LINE l.t No.L Length aT tines Property Lina <br /> FILTER QED <br /> I 1 Distance 10 nearest: wets Foundation . <br /> Size ^��-- Nllmher <br /> SEEPAGE PITS I l Dupth � � PropenyfLinof—SUMPS <br /> I I Distance to neatest: Not! Foundation��- <br /> DISPOSAL PONDS 11 <br /> {hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances.stale laws,an <br /> lutes and regulations of the San Joaquin Local Health District. y p <br /> Home owner or licensad agent's signature Certifies the following: I certrf that in she performance of the work for which this errrtt is issued,I shat!not <br /> employ any person in such manner as Eo became subject to workman's compensation laws o1 California."Contraclor's hiring or Sub-contracting signawle <br /> om0l y the following:in: u h ma That s the performance of the work for which this perrnil is issued,I shall employ persons subject to workman s eompertsa- <br /> tion lays of Califolnia" - - <br /> 7y>g ust call f all u- inspect ions.Complete drawing on,rawarse side- <br /> Title: <br /> Dale: <br /> Si nod X_ - <br /> FOR DEPARTMEAT USE ONLY <br /> - t date � �..�-Area <br /> Application Accepted by Date <br /> Pit or Grout inspectionDale Final Inspection by by <br /> Additional Comments: <br /> 1 ❑Stk 466-6781 ❑Lodi 369.3621 ❑Manteca 823.7164 ❑Tracy 835-6385 <br /> Applicant-Return all copies to:Environ ental Health Permit/Services 160t E.Hazelton Ave.,P.O.Bo.2009,Silt,CA 9520[ <br /> - FEE AMOUNT DUE AMOUNT REMITTED. 0 SH RECEIVED BY Dw7E---- --PERM11-h'0:-- ----- ---- ------ -- - <br /> INFO <br /> -.EM 13 24 IFIEV.rr„sr ---ya [• <br /> EH H-7e <br /> r . <br /> 1 <br />