APPLICATIO_{ .FOR PERMIT
<br /> SAN JOAQUIN*LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZELTON-AVE., STOCKTON, CA
<br /> Telephone (209) 466-6781'
<br /> ��, �.i.. rf 'n tt:t t�, tfi ft $Oi�O� DC7 2f @sfm to na ngo ,1
<br /> PERMIT EXPIRES,1 YEAR FROM DATE-ISSUED .w6�, fiy el 10
<br /> 2 h r r :"s ,• , r ! o. T;; 3 .r. {Complete.in Triplicate}.rbc i ;'ozma! 1owi3?ucienl
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install,the work herein described"This application is
<br /> made in,compiiance with.San-Joaquin for sewage 1 r,No.,Ia62lfiorwell/.Pump.and the,Rules and Regulations of the San Joaquin
<br /> Local Health Dlstrict,��,, $ F ti.q,4 `§i lx 't ls;l*n y.;f4 tG .rte f# V 4Q;K F;c.i 7 )a ' to noiP ir-gx3 be
<br /> to noil3 D
<br /> City ' ,Lo#Size . PM
<br /> Job Address 7701. N.
<br /> 1'0.41;lkfioFlj I)3 Ve "-r tOCkt4Y}"Phone W 1= b2
<br /> " {y31iw�'dT1FlEte�.p ; `AddrBss� '
<br /> w_ a
<br /> Owner's Name � _. --•-�- —� �.-_.-�,,...--�:,.-
<br /> -ry &782' CI SS C-21 Phone
<br /> Contfactor's Name , J@7G7CY & Ba7'b ; t DBense Na _ r
<br />' Y TYPE OF WELLIPUMP: i NEW WELL. El " -1 WELLAEPLACEMENT 11DESTRUCTION ❑. # r
<br /> r `-PUMP INSTALLATION. ❑ ,SYSTEM REPAIR © OTHER'D k s "'►" k
<br /> DISTANCE TO NEAREST: SEPTIC TANK, t SEWER LINES ; . DISPOSAL FLD. ti PROP LIME
<br /> EPITS/SUmm,
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL' -
<br /> :. ,.
<br /> z
<br /> INTENDED USE TYPE OF WELL; PR09LEM AREA CONSTRUCTION SPECIFICATIONS r 1
<br /> ` F Open. - - ❑ Manteca-
<br /> Dia. W6II Excavation -Dia. of Well Casing ,
<br /> Industrial- ❑ Ope Specifications
<br /> ❑ Domestic/Private El Gravel Pack Tracy Type of Casing
<br /> Grout
<br /> ❑ Public
<br /> -❑ Other p Delta Depth of Grout Sea! "type of d
<br /> '❑ Irrigation —M; _�Approx. Depth
<br /> El Eastern Surface Seal Installed by
<br /> Repair Work Done p Type of'Pump H.P. 8 State Work Done
<br /> I 11 -w
<br /> ..fe.. f - f' 7
<br /> Well Destruction ❑ Well Diameter* Sealing Material atop 50 1 .
<br /> 9 - Depth - Filler Material {Below 50') i
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ xREPAIR/ADDITION 1:3DESTRUCTION)MINo septic system.permitted if public sewer is
<br /> -..� _.- .. - w available within 200,feet.l
<br /> Installation+WWII serve:-,,Residence Commercial Other
<br /> k. _ '%
<br /> Number of living un-its: Number of bedrooms
<br /> ;�- . Water table de�ith"
<br /> t Character of soil to a depth of 3 feet:
<br /> ,., ' Capacity 'No: Compartments }�
<br /> SEPTIC TANK: ❑ Type/Mfg ?
<br /> ,} ,ya �'' �' Method of Disposal O�
<br /> PKG. TREATMENT PLT.![]
<br /> f Distance to nearest:' Wella Foundation Property Line
<br /> ' :.
<br /> LEACHING LINE -t s ❑ No. &1Length of lines Total length/size
<br /> .. ;, .P n Property Line :' `
<br /> I FILTER BED ❑ Distance'to nearest. Well r Foundation t
<br /> SEEPAGE,PITS ' ❑ Depth, t Size Number
<br /> I- SUMPS 1 t ❑��"SDistance to nearest: I- "Well Y i h Foundation Property Line f
<br /> DISPOSAL PONDS ❑
<br /> k 1 hereby cert!fy'that l have prepared this application and that the'work will be done in accordance with San Joaquin county ordinances, state laws, and
<br /> rules and regulation's of the San Joaquin Local Health District. W
<br /> Home owner or licensed agent's signature certifies the following: "i certify that in the performance of the work for which this permit is issued,,1 shall not
<br /> employ any person in such manner as to:become subject to workman's compensation laws of California."Contractors hiring c sub contracting signature
<br /> ' certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa
<br /> . -tion laws of ornia."
<br /> The applicant cal"for all i i pectians. Complete drawing on reverse side: ri r I
<br /> !�'
<br /> r , �,� r • flwne"r -28-85
<br /> Date:
<br /> rSigned tiT Title: - t 4
<br /> I MR DEPARTMENT-USE ONLY Area
<br /> i # __ -. . . .. ��'-
<br /> =- - i r�. !
<br /> Application Accepted by Date
<br /> t ' Final Inspection by Date
<br /> Date
<br /> 12
<br /> Tip
<br /> I ;
<br /> Pit or Grout Inspection by I( ..
<br /> ' - ., -.
<br /> krAi,!tional CommentCom . 0 LodiManteca 823 7104 ❑ Tracy -835 6385Applicant:- Return all copies to
<br /> Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201
<br /> i } - AMOUNT pUE AMOUNT REMITTED JED BYCASHRECEIV ..DATE PERMIT'NO:
<br /> :-FEE-
<br /> NFO
<br /> �s , -s S 7 s
<br /> +�EH 13-24'REV.141631
<br /> EH W26 - - - - - - - - .
<br />
|