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M1 APPLICATION`FQR,PERMIT
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<br /> SAN JOAQUIN1,0CALvHEALTH DISTRICT i
<br /> 1601 E.,HAZE,TOWAVE., S,TOGKTON, CA
<br /> Telephone (209}:466-67b1 ,
<br /> 46-6 6781 Y
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<br /> PERMIT EXPfRES 1,Y,EAR FR�?M I]AT,E.eISSIED.
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<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des(cribed' This"application is
<br /> m8dean coil7pliance with San;Joaclum.County Or finance No 6499-ior sewagekor.No,,,1862 for-wellfputnpk,,ai)d the'Ruies andI.Regplatlohgcf the San;Jo-aquin
<br /> Local Health Districtli0i'A Ito Z i^ ,ff"t f. s
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<br /> Job Address , ,. .
<br /> rDN ja'a stD�6;o. ASN Loti51ze1t -t"�Iy1a . .,.
<br /> Owner's Name Address +
<br /> ;Contractor5,Name,C��' �t r&t Ll License"No. Y 3d - Phonei
<br /> TYPE OFWELL/PUMP:. i NEW WELL ❑ '' WELL REPLACEMENT D
<br /> j DESTRUCTION ❑ 3 '
<br /> 1 a __r.. ._--
<br /> 7-- AIR i] 1 OTHER"❑ i
<br /> r PUMP INSTALLA.�'7�ION�❑-� I SYSTEM�F?EPi
<br /> DISTANdE TO NEApEST, -SEPTIC TANK - •' SEWER LINES L DISPOSAL FLD, i
<br /> PROP.
<br /> LINE
<br /> FOUNDATION i AGRICULTURE WELL! f 'OTHER WELL S UMPS
<br /> PI S/ 11
<br /> .4-
<br /> INTENDED.USE } TYPE EOF WELL PROB!_EM AREA .CONSTRUCTIONSPECIFICATIONS
<br /> •, �❑ Qromestic/Private '❑.Gravel Pack ❑ Trac ; � -.; .Well Excavation § ---� �- `- ---•.�Qia of Well Casing;
<br /> l ial .- ❑,'Open-Bottom ;❑ Manteca Dia.�of
<br /> ; y Type of Casing i5pec�cations
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<br /> -E] Public i ❑ Other . i. `❑ Delta Depth of Grout Seal Type;of Grout,
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<br /> 40 Irrigation - - F �pprox:Depth. ❑-Eastern- Surface Seal Installed by
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<br /> 71
<br /> Repair D W�uct ohDone
<br /> ❑ We l Qf mete-Pump
<br /> r I tSeaiing Material !top 30') _.5tate Work Done
<br /> Well'
<br /> Depth 4!, - -s- (Below 501 !
<br /> ?, � `.Filler,Material -
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<br /> - TYPE OF;SEPTIC WORK:°-NEW INSTALLATION EPAIR/ADDITION'❑ 'DESTRUCTION EJ (No septic system permitted if.public sewer is'
<br /> a i,. .available within1200 feet:} q
<br /> + - -
<br /> 3 e Commercial_ Other
<br /> Installation will serve:+ Re}idenc +-�
<br /> M1Numbei of'living.units. ![. 'Number of bedrooms
<br /> a
<br /> x rrR fi deptof3feetCharacter ofsoil t6a ._
<br /> ' iWNatertable d pth!SEPTIC TANK R—HType/MfgCacit o,
<br /> Compartments ,
<br /> WG. TREATMENT PLT' ❑ 'Distance to nearest: i T
<br /> ��� Wethod M h of Di o al
<br /> f r { f .�._ "Well "�F60ndation ['� Property Lillie'
<br /> # LEACHING LINE L9�No & Lerigth of lines ! Total length/size
<br /> I
<br /> " FILTER BED {` r' ❑ (Distance tb nearest;E Well; Fqundatin '"_Prope"rty•Line
<br /> SEEPAGE PITS_._ ❑rvDepth ._,. _, '- Number s -
<br /> s 5¢e _
<br /> "(SUMPS`"" ❑ distance to nearest; {Well Foundation
<br /> DISPOSAL PONDS to411Y }
<br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin,county ordinances state laws, and
<br /> -�-*�rules-and-regulations-of She-,Sen Joaquin•Loc ai-Health i]istrict:
<br /> Home owner or licensed!a ent's signature certifies the followin _ th or _ ' - � x- r
<br /> } 9 9 g:;'i certify that in the performance of] work for which this permit is Issued;I shall not
<br /> femplo any pepon insuc'h,manner?as•to-becomesubject.to work man'sfcompensation laws of-California."Contractor's.hiring.or:•sub-contracting•signatu re-
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<br /> 4 certifies a following: "I certify that in the performance of the work for which this permit' is issued,I shall employipersons subject to workman's compensa-
<br /> i tion Iaw5 io .aiifornia: -- - -- !
<br /> The,applican st call r all quired i s ' ns om lete drawin o revers` side a a i I t
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<br /> Signed ! I. Title ; - Date:
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<br /> FOR DEPARTMENT USE ONLY 1 r !
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<br /> Application Accepted by I ' i
<br /> Area
<br /> s-•:- . -,�....._.�_�. tion ti
<br /> Date
<br /> Pit or Grout Inspection by o- ! Date Final Inspection ata i
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<br /> Additional Comments; �b I i l i I i- D I �
<br /> -Stk -466.6fBi--i—^-� totli-- !
<br /> --0 Manteca 823-7f04-�--�—C},Trac'y-°^835
<br /> !Applicant`-Return all copies to: Environmenial Health Permit/Services 1601E Hazelton Ave:; P.O. Box 2009,�Stk.; CA 95201 i
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<br /> j J !INFO IAMOUIVI DUE.E AMOUNT fiEMITTED� C SH i RECEIVED BY t !)ATE PERI4AIT"N0
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<br /> +EH 1324(REV.10!631 I s;~, ' ' l 1 „i i
<br /> EH 14-26 ..._._,_..i, i ; 13
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