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<br /> '- APPLICATION F,OR,PERMIT
<br /> SAN JOAO,UIN,;LOCAL kff ALTH DISTRICT
<br /> 1601 E. HAZELTON,•AVE., STOCKTON, CA
<br /> 4 Telephone 1091 46G-6781
<br /> i{. s ni§i '"SIS ' mits r ) -•k `�'9 i.'�f� GF r".E_:7 -iii P.:les I, a Y e . I �l/
<br /> 'I PERMIT EX13111 s 1 Y. AR FROM„D�ATIM. ISS—�--F ;? _v� =+.�t,s;r
<br /> r(qp Tlp)etInjT[IJJIIca eM `.. ?d's fl^'!;r'iFs',::;;�e?i'tss Ysite}f5 'r^, 4�<r� )rl r
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here t 116kribedi Thfi�4 plication is
<br /> madea ' plianea.with San Joaquin Ggunty,Ordrnance'No S*.for sewage o the San-Joaquin
<br /> Local Health jC r i o r r e; r � s_ t• r
<br /> ry 11�Wait I "„h r f 3 y
<br /> _ , v s , i5 1 tris 4,r+ r , } r ✓� r P 9 3"� fr !��-,!�- �_
<br /> Job Address tJ C,.Zik dCrty Lot Slae PM
<br /> ' nz
<br /> Owner's Name- � /� �X �6
<br /> l
<br /> IContractor's Neme E License No t_ _ Phans, ,it
<br /> f
<br /> �- TYPE OF WE6LIPUMP NEW WELL El-', WELL REPLACEMENT ❑ DESTRUCTION El',
<br /> I j
<br /> -PUMP INSTALLATION' I '�SYSTEM;REPAIR-p _i + "OTHER ❑" .. j
<br /> Y.
<br /> D15TANCE70 NEAREST SEPTIC:TANK �� SEWER LINES_ � I 'DISPOSAL FLD.J7 P _ PROP. f_INE{V j
<br /> } FOUNDATION AGRICULTURE WELL-' ' ' ;OTHER WELL PITS/SUMPS ZOQ !
<br /> INTENDED USE TYPE jQF WELL° PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> j.._. O dnilustriak_ pe �Bottom ,-.:.... _ . : , �.Qia._Of.Well Casing . .�
<br /> - ,--❑ O ❑-Manteca Dia. of Wsll.Excavation. ,
<br /> ❑ Public
<br /> r._!____;_ -Prrvatet ❑ Other,”, ' P - Specifications
<br /> Pack ❑ Tracy Type;of Casing
<br /> - ❑ Delta De th of Grout Seal �' M Type;of Grout " — '-
<br /> w_.- Seal f....._ i ;
<br /> r---- ❑ Irn ativnJ-- -- --}- - �pprOX. Depth - 0 Eastern � �Surface-S d by.'. .
<br /> {Repair Work Done ❑ Type of Pumpf� H P till p State Work'Done
<br /> ,.. ;.
<br /> i _.
<br /> Well Destruction ..8�
<br /> ❑ Wel! lame Sealing Material Stop 50 1. ) I i l��i S �
<br /> i - -..
<br /> Depth . -.Filler'Material (below 60'f
<br /> TYPE OFiSEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION'❑ DESTRUCTION❑ (No septic�s stem permitted if public sewer is
<br /> availablwithin 200
<br /> eed -I
<br /> Installation Wilt serve Resident Commercial Other 4!
<br /> 1 Ins ,
<br /> TI J$ �J
<br /> t f Number of Irvin units: Number of bedrooms a
<br /> t r r ter of soil to a depth of 3 feet: I �' Watar-table depth�-
<br /> `SEPT TANK! z ❑ Type/Mfg` �� t� Capacity Nv Compartments ' r ~
<br /> PKG. TR r z _. .__. ,,.... _ _.
<br /> Character - -
<br /> - _. - . -
<br /> EATMENT PLT e❑ 1 � .�� 3 -_ { , 3 1 MetFiod of Disposal
<br /> .,Ols ` > r Poundal i
<br /> ten a to n arest.r Weill ,ion —Property I
<br /> Line r -
<br /> LEACHING LINE ❑ iNo. & Length 6i,lines V' L'V` `^ {.l gth
<br /> k
<br /> FILTER'BED-' t "❑ ?Distance'to-nearest i Well;y Foundation ' ; Total.le Frope`rty Line
<br /> f
<br /> 71
<br /> t� € SEEPAGE PITS ❑ ;Depth Size Number,
<br /> t I SUMPS -I...._ i❑_ Distahce to nearest. ,_,,Well. w ._ ._ Foundation "' .... ...Property Line
<br /> F` :DISPOSA`L PONDS' ❑ l ! s .\i , + i g
<br /> i I hereby certify that 1 have prepared this application and that the;worktwill be done inl accordance with San Joaquin'county ordiijances state-laws, and
<br /> i_.. }rulei-and;regulationt of the Sen-Joaquir-Local-Meath District _4_ 5-_. € •._.__L .,_�,_._; . _. �. -. �.m._ _, . ..
<br /> i 1Home owner,o'r licensed.agent's sjnatuIre eert'rfies;the following. ',1 certify that in the performance of the work for which this permit is issued,il shall note
<br /> I-------employ-any-person-in such rronner,aa-to;.� me subiect to-workman's compensation,laws•of-Califomia."-Contractors hiring or;sub-contracting-signature.
<br /> Scerffiies the following: I cern than in the ante of the work for which this permit is issued, I shall employ persons subject to workman's compensa-
<br /> ' !__..?tion laws-sof-CaEifOr a, - .,t..� _ �rform!V
<br /> C� !
<br /> IThe applicant must call for all:required inspections. Complete drawing'on reveres side.
<br /> -;._... .!M- �,......�..., �
<br /> Signed s title: (�tJ I� (.[fid✓ i Date:
<br /> P RTMENT'USE ONLY
<br /> ;_•-
<br /> Application Acce ted b .. .� � ,_ 4^.__.�_,..y,-' ...t:;;1 � }__•-••• �!:.M i r_
<br /> FOR l7EPA
<br /> ! } ^Pp, p Y! w iii' Lt i Date 1 r�i Area
<br /> i I Pit or Grout Inspection by �:. ! Date _____�T Final Inspection 6y
<br /> !, Additional Comments _M 71
<br /> -.v
<br /> IG slit_ 4666781 ! Lodi 3�9 3621 ❑-Me'
<br /> 823 04 _ . .
<br /> Applicant;- Return all copies to Environmental Health Permit/Services'1601 E. Hazelton Ave P.O. Box 2009 Stk CA 95201 I
<br /> ,
<br /> — + ' AOUNUE ` CK TED RECENE6V5
<br /> INFO r CASH r d r PERM T"NO
<br /> l + EH 1324(REV.
<br /> ' s
<br /> !H,14-25 4 r I ( 5 C3 0 47'I 3 4 x-"11 — i i� QZ!_� I
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