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t' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone =91 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CompleTe in Triplicatel <br /> Application is he+aby made to the Son Joaquin Local Health Dlrtrict for a parmil to consvum andlor install the work herein described. This application 11 <br /> made in cornplia+tce with San Joaquin Caunry Ordinancu No.549 for sawaip or No 1BU for welllpump and ilia Hui"and Regulations of the Sari Joaquin <br /> Local Hedllh 01strict <br /> Job Address CIty Lsweig—C— Lot Sue r PM <br /> 71� fr V. <br /> Owner's Namor•a^J � Q Address ff Z ����tr-��--,,. Phone <br /> Gtinllaclor v Address o License No.�Phone + <br /> TYPE OF WELL)PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION C_] <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER i ] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PAOP- LINE <br /> FOUNDATION AGRICULTURE WELL OCHER WELL PiTS1SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> ID Industrial 0 Open Bottom L1 Manteca Dig. of Wag ENCavatian Oia. of Well Casing _ <br /> Ci Dornesticiptivale ❑ Gravel Pack 12 Tracy Typo of Cooing Specifications <br /> I'l Public FI Other Il Dada DWh of Grout Seal - Type of Grout . <br /> I I Ir-umton — Appian. Depth I I Eastern Sipiace Saef Installed by <br /> Repast Wank Dares [, Type of Pump _�� H P. State Work Done _ <br /> Well O"truclion L Well ❑Iameter Sealing Material Itop 501 - — <br /> Depth Filler Matenal 18elow 601 <br /> TYPE OF SEPTIC WORK: NEW 1NSTALt-ATION REPAIAiAp01T10N I I DESTRUCTION I I (No septic system permitted 11 public suwur q, <br /> awailablis within 200 leol.l <br /> Installation will serve- Rasigen-0 A�Cornimf ial Other <br /> Numbof of living unies: Ii Number of rooms <br /> f <br /> Character of sod to a depth of 3 feet, Water table depth_ 3 <br /> SEPTIC TANK Type/MfgE C&Wity No. Comparte mnts t <br /> PKG. TREATMENT PLT ( I ^ Method pLL),Wsal <br /> Distance to nearest: Wait Faummmorl r Property Line —S— T <br /> LEACHING LINE Il:_-­No. E Lemglh of Goes �T0 f Total langthlsite <br /> FILTER BED I 1 Distance to nearest: w 11 - � S�f Fwndltiion x� Propony Line <br /> SEEPAGE PITS y "t^Dnptn . _ Sea dumber ., <br /> SUMPS I Distance to rwaresi: Wait FRundaiton _ Property Lino �i O <br /> DISPOSAL PONDS i i <br /> I hereby candy that I have prepared this application and that the wor* will be done In bccwdance with Son Jo"Liin county ordinances, state laws, and <br /> tulas and rayutalwns of the San Juaquin Local HeslM Distncl. <br /> Horne owner or Ircensbd a¢ent's signature cartiftes tt,e fo"ing "I canny that in the performance of the work for which this permit is issued. I shall not <br /> ernptoy any person m such manna(as 10 bacomw subject to workrnarr's compensatkrn laws of California " Conuactor's hiring or subcontracting dgrtature <br /> corlifics ship following: "I cartify that in the performance cf the work for which this pe(m+l is issued. I shall ernploy persons sublaci to workmen's compensp <br /> lion laws of California-" <br /> The applicant must call for aft eau' inspections. Complete drawing on reverse side. <br /> Signed X Title: hate: <br /> FOR DEPARTMENT USE ONLY <br /> Aaplrcarion Accepted tly Data u" Area r <br /> }� <br /> or G+autlnspection by Data Final lnapeCtipn by ate <br /> Addrtitnal Comments: <br /> 1 1 Sek 466.6701 ❑ Lodi 30-30 Z) Manlnca M-7104 i_I Tfacy M5•6395 <br /> Applicanl - Retutrt till copies to: Envuanmantal Health PorrnitIServices 1601 E. Hexalton Ave„ P,O.w2009o <br /> SM., CA 95MI <br /> FEE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PEAMIT NO. <br /> INFO <br /> CAS1i <br /> Eat t)N inry 1 f ! lt"t/ � <br /> Er+ 14 ae ��.-Jl VVV <br />