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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT �� �• <br />` 1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone 12091 468-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />1Corriplete in Triplicate) <br />Application is hereby made to the San Joaquin local Health District for a permit to construct and/or irrstsll the work twain described. Titan <br />made in compliance with San Joaquin County Ordinance No, S49 for application is <br />Local Health District. sewage or Na. 18ffi far welllpump and the Rubes and Regulatitrrrtt of ttte San Joaquin <br />Job Address City Sive _ <br />PM <br />O+amer's Name <br />_ t Address Phoft <br />C oratracstr1 _Address . L ...`F R.,`..= License No. &ZI13— Phone `j(w <br />TYPE OF WELL/PUMP: NEIN WELLWELL REPLACEMENT DESTRUCTION <br />PUMP INSTALLATION Q✓— SYSTEM REPAI113 C OTHER t3 <br />DISTANCE TO NEAREST: SEPTIC TANK JOL+_ SEIWER LINES DISPOSAL FLD_____ PROP. LINE <br />FOUNDATION - AGRICULTURE WELL OTHER 4WELL PITS/SUMPS <br />INTENDED USE <br />C Industrial <br />��amestiaif'rrvate <br />Public <br />C Irrigation <br />Repair Work Done <br />Wail Destruction <br />TYPE OF WELL PRO CONSTRUCTION SPECIFICATIONS <br />Open Borttorn ✓� I j Mu►rrtece Dia, of Well Excavation Dia. of Way Casing <br />416-001 Pardo O Tracy Type of Casing,,.._. Spwcilications <br />u Other C Dana Depth of Grout Seal, <br />--.�.yrr_. _... Type of Grout JA <br />___App` Depth O Surfa Seal Installed by �,rm.�,- <br />Type of Pum H.P._ �. �_.__ State Work Done <br />Well Diameter Sealing Material (top Eli') <br />Depth Friler Material (Below SD') <br />5RK: NEW INSTALLATION G REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if n kdi, <br />• <br />)nstallatian will serve: Residence ____. Comrrierciai _.. Other available within 22W feet.) <br />Plumber of living units: Number of bodroomr; . <br />Character of soto a depth of 3 feet: ~�� Watarwater die <br />SEPTIC TANK J Type/Mfg r•" `=--- depth <br />Caps — _ No. Comparnrrenta <br />PKG. TREATMENT PLT. C <br />Method <br />i + of Deeq " <br />Distance to naaraat: Was Poundat" _ Pnoparty Lula <br />LEACHIN13 LINA s 2�' 7Yt3. B�Liwagth of -- - Tio4id Ler (labra <br />i`iLTi em a Distance caress: 1 Foundation ho"W Ultra <br />.... <br />SEEPAGE PITS� <pep sire <br />SUMPS /'/ 0 ,- 151stance to nearest: Weil _ FoundationProperty Lain <br />r7rfiiyrtC n i mn c t "-�--�----... <br />sewer is <br />prepared this �rllC"on Ind the the work will be done in accordance with Sara Joaquin coo <br />I hereby certify that I hares q mY ori, a , and <br />raise and regyul he San Joaquin•i..� Health District, <br />Horne ow or licensed a s aignat ire cecina the fo : "l clanify that in the performance of the work for v+rltich this <br />employ a person hr such nor as to becurr+w su " Ciarrrtit is issued, 1 shall r'at <br />Certifies following. "I in the s compensation laws of California.', Contractor's hiring or sub•corctracting 'signature <br />of th work far which this mit IS issued, i Shail emoloy persons subject to workman's c ompa nse- <br />tion of C..aii#ornla.' <br />The ap nt or 1 requir oft dr arra. <br />Signed <br />FOR DEPARTMENT USE ONLY <br />Application Accepted�1,6y <br />Date <br />Pit of Grout inspectioDateFinal Inspection tyy3as4aa <br />Additional Comments: I o) 4 t) �,✓ �- rf 4 a � by <br />C Stir 488.6781 P Lodi 389-3821 Cl Manu 823.7104 O Tracy <br />Applicant - Return air copies to: Envh'ontnargai Haalth PereSarvites 1601 E. F#iaettorrr Ave., P.O. Boos 20s, Stk., <br />+ EM 33.24 rssty, r e a 6 <br />EN 34-25 <br />FEE <br />INFO <br />AMOUNT + <br />AMOUNT R>:rxilTElS <br />Csi5H RECErvw By <br />DATE <br />PERMIT.NO. <br />FA <br />