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APPLIGATION'FOR'PERMIt'k'
<br /> SAN 'JOAQUIN LOCAL HEALTH UVSTRICT"t
<br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO
<br /> Telephone (209) �66-rVB .
<br /> 1C.- U1 A.
<br /> DATE ISSUED
<br /> PERMIT EXPIRES,)1:,YEAR'!FROM,.DATE'ISSUED<"1.,'i$t,
<br /> -A,Complete ln:TriP
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/Dr. install the-wo&hereini t,
<br /> I I I
<br /> ;,,described.,("This�appllcationv
<br /> -itimade:in,compljance�with Sari"Joaquin'County'Ordinance'No.'-540!for sewage.or N6., Aw�01r!IW411.'pump
<br /> and the Rulds and eg.yl e.San oiq Lo I Health 4
<br /> %,-j,
<br /> Subdivision_ Name
<br /> Job Address
<br /> Owner's Name .47
<br /> ;Addressor yeiv_i,Phoi
<br /> Contractor's Name _�eCo,)rt 1��S License No. Phone Cl ZL 112.ZL_,_.W
<br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION
<br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ED C>
<br /> LINE
<br /> DISTANCE TO NEAREST. SEPTIC'TANK' SEWER LINES DISPOSAL FLD. J00. PRO,.
<br /> 2ra PITS/�SUMPS
<br /> AGRICULTURE WEL OTHER WELL
<br /> FOUNDATION-:--
<br /> INTENDED USE TYP'E OF WELL PROBLEM "AREA 'CONSTRUCTION SPECIFICATIONS
<br /> M Manteca
<br /> industrial Op6n Bottom Dia. of Well Excavation
<br /> RDo.esti�,/PrivatO ravel Pack El Tracy Dia. of Well Casing'
<br /> __j Public Other 0 Delta 'ing
<br /> Type of Cas
<br /> Irrigation )x.: Eastern
<br /> I Approx.` Specifications
<br /> Depth
<br /> O-Cathodip!. Protection
<br /> Depth of Grout Seal.
<br /> Fj Geo
<br /> Type of-Grout
<br /> Geophysical'I
<br /> Other �,.Sdrfacel*-Seal,Installed
<br /> Do
<br /> 1_16one' Ae
<br /> Rep"a'ir Work T p oi, ulmP' State Work�Done,
<br /> Welh_Des tru9'ti on' Sealing Maieriall-(t6p 501-)
<br /> F D -well Di'ameter
<br /> Depth
<br /> I Fil 1 er'�Mate'rial, (Below 50'.)
<br /> TYPE OF SEOTICIWORKI: NEW INSTALLATION Ej RE!PAIR!/ADD'ITION Ej- (No septic tank :0r seepage-pit permitted if pudic sewer is
<br /> i i i t available within 200 feet.) 1
<br /> r
<br /> Instal latio, !w,11 serve: ;Residence Commerciall Othe
<br /> ;Number of living units: Number!of bedrooms"_1 Lt size I
<br /> depth -�f-
<br /> 0aracterl-of'soillt, a 3 f!e et: i iater table �epiii
<br /> No..1 Compa
<br /> SEPTIC TANK_ i Type/Mfg I Gapacp rtmentsf.
<br /> PKG. TREATA&i�PLT.1�El 0 pac"Ity posal
<br /> Type/Mfg Method of Dis
<br /> we�;fl-
<br /> Dilstance to nea�est-� tion _j Propert1 Line
<br /> LEACHING LINE I[—I Na' 91"ength of1lines Total 16ngth/size I
<br /> foundation
<br /> 6. erty-Line
<br /> I!LTER:B 'p
<br /> F1 ED Di�tance td.-nea est:� •We!l i
<br /> ED L
<br /> I , r
<br /> SEEPAGE PITS i I[] Depth •Si i zel- Number
<br /> MPS Foundation Pro've y i
<br /> I Distance ta� nearest:' Weil rt' Lide
<br /> SU
<br /> it
<br /> DISPOSAL PONDS
<br /> certify that I !have!prepar4this appilicaiion iand that'the Work wi 11, be donetin accordance` with San Joaquin 1couniy
<br /> 4
<br /> I hereby cer
<br /> ordinances,£ sta�te liws, and 'rules' and!reg6l ati6ns O'f..,tHe Safi Joaquin',L-oval -Hdalth 1 Disirict.
<br /> I i it
<br /> Hdne owner!pr licensed agent's si�6nature certi.fiesl the!fol lbwing: I'll certify Xhat�in the performance of he Workifor which th4s
<br /> 1 0
<br /> rM hall not employ"any person in i
<br /> it'is issued, I 1SrUqH,ma6er as to�.bec6me subject workman§ comoensati n1lawS of kal,Oornia.
<br /> t 4
<br /> 'Co%trac or is iringlor s',ljb-contracting-sig'-n-aiur'e c&t1f,,les the folloWng, "I ;certify that in the pe ormance of the work for which;
<br /> rsons �ubjkt toCalifornia. +
<br /> compensation 1 dws
<br /> ermit is issue , I' A
<br /> s . . .
<br /> P d shall employ�pe workman} cbm of
<br /> T
<br /> The appljgA'4z_must c 11 'for all r ui d in tions. jdraw�ng on rever eside.
<br /> .Compl ete q !_
<br /> Signed X ;Title: bit -Date:
<br /> A ONLY_
<br /> RfMEN,� USEi
<br /> j...
<br /> Applilcation Accepted by Area C3 Stk 1 466-6781
<br /> Lodi A9-3621
<br /> Additional Comments: ED
<br /> P+tor Groutilnspectl6n b Date. -'S 23-7104
<br /> X Manteca 8
<br /> 835 6385 Final Inspection by bat Traci
<br /> Applicant RetUrn all coplei to: En�iro6manl;M H�alth Perrhit/Servi�es,1601.�E. H:zelfon Ave., tP.O.:Box.2009,- Stk; CA
<br /> e.
<br /> k d r
<br /> d '
<br /> - ess -jc Phone License
<br /> se No.
<br /> h
<br /> -AMOUNt_R MITTED- - RECLVE61Y- IT NO,
<br /> bATEt PERM
<br /> PEE jj BASE I AMOUNT_ -,DUE E
<br /> INFD! 00 ,
<br /> �44
<br /> 1 ;1 T
<br /> Et 13-,24 1 REV: 10/,82 10/82 MO t
<br /> 1:
<br /> 1426 j J
<br />
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