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ey w"rye <br /> i <br /> APPLICATION FOR PER"IT <br /> 7 <br /> SAN JCAQLiN LOCAL HEALTH <br /> DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � <br /> Telephone (209) 456-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the,San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1852 for well/pump <br /> and the Rules and Regula ti ns of the San Joaquin Local Health District, <br /> Job Address 03 LAJJ4�v= LW . 00 <br /> Subdivision Name <br /> Owner's Name L Lddress ISA r3lF- Phoneg1­07-so> <br /> Contractor's Name p��y SAI ¢ 1'pAS License No. MC-4,143 Phonet".¢}�_, <br /> TYPE OF WELL/PUMP WORK. NEW WELL WELL REPLACEMENT DESTRUCTION O6 <br /> 1 PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE 1 <br /> FOUNDATION F AGRICULTURE-WELLY w OTHER WELL PITS/SUMPS <br /> { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C i <br /> 17 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack Lj Tracy Dia, of Well Casing <br /> LJ Publict. <br /> ❑ Other Delta Typefof Casing <br /> ❑ -Irrigation Approk'"-^"Q-Eastern- <br /> SpecificA <br /> tp' ations <br /> ❑Cathodic Protection Dep ;h <br /> t v s an 11Depthof Grout,Sedl <br /> Geophysical ! 1 } Type of Grout;I <br /> ❑Other yP' a <br /> Surface Seal Installed by <br /> Repair Work Dane ❑ Typelof Pump 1—H-P-.- State Work Done 1 I <br /> WelllDestruction ❑ Well �D ameter Sealing Material (top 50') { <br /> t_ DePMl Filler Material (Below 50 + <br /> ) <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION ❑ REPAIR/ADDITION _ (No septic tank or seepage pit. permitted if public sewer is <br /> 1 <br /> available within 200 feet, <br /> Installation will serve'-, Residence k Commercial Other i <br /> Number of living units Number-of bedrooms �. _ Lot size <br /> Character of soil to a dep +� of3 feet: ? fes f g t Water table depth <br /> SEPTIC TANKTypeJM.fg+ ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg,; Capacity Method of Disposal _ <br /> SEWAGE SYSTEM1Distance tv nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ Id <br /> LEACHING LINE LNo, & Length of linesTotal len 9 <br /> th/size <br /> FILTER BED *Distancei,'to nearest: 'Wef).,AW '0' Foundation -te Property Line <br /> SEEPAGE PITS Depth. Size Number r <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSALI PONDS CG <br /> I hereby cerf_ify that!I haverpr-epared this'pplication and that the work'wi11'[e'done 'in accordance with San Joaquin county <br /> ordinances, state laws, And rullesXand regulations of the San Joaquin Local Health District. <br /> E <br /> Home owner orlicensed agent"s signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued shall not•.employ any person in such manner as to become subject to workman compensation laws of California." <br /> Contractor's h" g or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit i ss dl I'shal,l employ per ns subject to workman's compensation laws of California." <br /> The appl ica m call fo {11 req�-i,�Spns. Comp to d g on reverse side.Signed X rTitle: Date: I �I/r D <br /> € I �D MENT, ONLY "` rF <br /> Application Accepted1by .fi71.G Area LStk =466-6781,-�' <br /> Additional Comments:"'~ ` r Lodi 369-3621 <br /> Pit or Grout Inspection by Date LJ Manteca 823-7104 <br /> Final Inspection'hy moi., 4 Date AlL Tracy 835-6385 <br /> Applicant - Return all c p es to:J Environmenta-1, Hea,ltth1Permit/Services 160[ E. zelton Ave. P.O. Box 2009, Stk., CA 95201 <br /> - w^TFEE�,.,..BASE-.,, .�„_AMOUN7�t'lUE- I.AMOUNT- ,,,_„RRECEIVED BY_ DATE PERMIT N0. <br /> 1NF0 <br /> EH 13-24 REV. 101,82 <br /> 10/82 500 <br /> «.142 6" --Z' <br />