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1111r7", <br /> APPLICAT1644,fOIR <br /> SAN JOAQUIN LOCAQ4EALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,5' CKTON, CA <br /> PERMIT.IPIRES 1 YEAR°FROM DA A; <br /> Telapfi�ne (209 , 6781 <br /> TE- $QED <br /> ICorxllete` rl Triplicate) ' <br /> 7.Application hereby #o tf►i1 Sari"Joaquin Local HeaFEfr pistrict for a pelt to cor�t`andlor install the work herein described•This a is <br /> N.made in coratpNance whfl San Jaaqum County Ordinance No.549 for sewage or No.VWfor well/pump and theRylesand Regulations of the San Joagriin <br /> Local Heafth Otsttrtct. <br /> ob Address ; <br /> city �. Lot Size PM <br /> AddressP <br /> Owner's Name -" <br /> y1t '���LA _Address 2&% �i" <br /> Contractor License No� _Phone <br /> TYPE OF WELL/PUMP: ' W WELL 0 W L REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Q. SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - _ PROP.GINE <br /> FOUNDATION AGRICULTURE WELL t)T Fi WELL <PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA „ C43NSTRUCTION SPEiFtCa IONS <br /> ❑-Industrial ❑Open Bottom ❑ Manteca Dia. of at' <br /> " Dia. of Well Casing 1 <br /> �" Speci lWjona <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Iras}n Q <br /> • Public l Delta Depth of Grant Seal Type of Grout F <br /> ❑ Irrigation "�` � aP ❑ Eastern Surface Seal Installed by (� <br /> y Repair Work pone '❑ Type of Pump �- H.P. S Work Done <br /> v II Destruction ❑ Well,Diameter _— Sealing Material Itop 50') <br /> Depth Filler Material( u 50') " <br /> TYPE O SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ "DESTRUCTION CI (No septic system permi .if public sewer is <br /> avail"within 200 feet.} <br /> abtkmn _ <br /> -4ommetedal----Wer - <br /> Number of living unite: Numbenlsf bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC.TANK ❑ type/Mfg Capacity No Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> �f tACHIN�#�ffIUE ❑ No. &Length of'lines �. Total lengthfsize' <br /> FILTER BED ❑ Distance to nearest: Well Fou "y _ Property Line <br /> NISPOSAL <br /> EEPAGE PITS ❑ Depth Size Number <br /> UMPS ❑ Distance to nearest: Well Foundation Property,Line <br /> PONDS ❑ <br /> I hereby certify that 1_have preps#his application ar hat the work wIII be d7a7,4n accordance w ttr 8"Joaquin dotur ordtnsnces;steta laws;and <br /> rules and regulations of the San 4&Rluin Local Health ftrict. <br /> Home owner or licensed ager►#;s slgnatutt9.certifies.the RAW g:"I certify that in theI performance,of the work for whish-,thio It is issued,..l qot <br /> employ any person in such vneriner as tcs r,acome s4bject to workman's compensation laws of California: Contractor's hitthg or sub-cont[aa6ting e�gnpture <br /> certifies t following "I certify that in t%performance of the work for which tbis,permit is lssue i;I shell employ persons 04"V Awrktl:la �R,aompensa- <br /> tion laws df,Califota '--'M y -. <br /> -The applicant must call for all requiredoma7ns. Complete drawl n-reverse side., k <br /> Signed <br /> Title: ate: ` <br /> : FOTi DEPARTMENT USE ONLY A7Application Accepted by Date Area <br /> Dat Final Inspection by <br /> Pk or Grout Inspection by " <br /> Additional Comments: 08P <br /> f <br /> ❑ Stk 46&6781 ❑ Lodi 369 3Q'Li C1 Manteca 823-7104 TricY <br /> pp <br /> � 5 <br /> Applicant Return all so�p�o: Environf ealth PermiE/ ccs 1601 (w � •„p•O, BawSc ��Stk �u• <br /> u. <br /> 'r'yT "�'" 1W1 r NME <br /> FEE AMOU}li AMOMIT REMITTED" CASHRECEIVED BY: T <br /> INFO <br /> +EH1a•24Mv.,is5) 35.2, 17,177 p ik 8 <br /> EH 1428 <br />