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<br /> i APPLIQe TIONTFOR-PERMIT
<br /> SAN JOAQUIN-J;-QCAL�7HEATH DISTRICT
<br /> `s 1601 E.•HAZE I•QN AVE S1.T()CI ON, CA
<br /> Telephone Q01 466-6781
<br /> it tP�``Ji,".'.',
<br /> fcaitr S F t od.DQT
<br /> II PERMIT EX$'IRS,1*YI ► FROMI ,I~ I$Sl3ED;�e;,F4 � ;3s; s{ , r ;'it �ltirsr
<br /> i rY , z � e" 1_.1'�,:.r3'"1�3ci 1;,�33I,�`.�.�4i}� ;t4�ompteteMltn. T�iplicatel..l..-•il„�i t,.,,'R94.+1e.:;:�11.� �i r.:`i 1+f.�ti�r}rid+�.'1-y F11 a .i.;�.
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein'de=scribed. Thts'epplication is
<br /> rrla01n°compliari,ce with3San Joaquin County.,Ordinance No 50 for,se go�9r;No !!for;welt.0ulnppa I tlfe,lRuleswd Regulations of the Sanwcaquin
<br /> Local Health District-10i
<br /> iyy r l} f44ti ; �F}r t s Irl a "�( " k F a fi b` 4s4 � t rd 7 7o
<br /> Job Address -`� �',. C+ty,,, v. .. .,.... of}Sine, _ 6P :..,,.
<br /> Owner's Name ' Address Phone
<br /> i Confractor's_iVame g } License_No. ` } i Ph
<br /> _ _
<br /> ^ }TYPE OF�WELL/PUMP NEW W ❑ i WELL REPLACEMENT 0`.r�', DESTRUCTION ❑ a
<br /> l t _ E ` -
<br /> }� PUMP INSTALUA rlON-❑ I SYSTEM`REPAIR ❑ F " OTHER' ❑, E
<br /> �DISTANCEtTO_NEAREST:-SiPTIC TANK._� --,---... _SEWER ES
<br /> �.----.. DISP05AL_FL'D_ P-ROP LINE'=- ----,.
<br /> ! k (OTHER WELD } PITS/SUMPS
<br /> } FTOYPEOFIWELL !PROSLEMAREATUCO STRUCTI.' �
<br /> i _
<br /> J INTENDED;USE _ i ON SPECIFICATIONS ! [ !
<br /> -c~ El❑ Ddustri clP vate ©- er Bottom ;- - ❑ Manteca - Dia.of Welk Excavation --! J_ Oia.-of Ca
<br /> Well sing;
<br /> p
<br /> + ❑EO Gravel Pack !❑ Tracy ' Type of Casing_ '
<br /> 9S
<br /> � pecifications
<br /> .Y,
<br /> l rox. De h ;C� Eastern Suifaca S seal ! Type of Grout t
<br /> i ! 1.�. IS } i i
<br /> f g - 1 staAed-by
<br /> i El Public ❑Other I ❑ Delta , Depth of Grout
<br /> ❑ Irri ation _.. _ � qpp + Seal In
<br /> I I , State Work�Done + I
<br /> Repair Work Done i © Type of Pump H.P.4_
<br /> :Well'Destruction 1 ❑ ' Weil Diameter ! -Sealing Material atop 50'l
<br /> " flepth.:� �+LFiller ltFaterial (Below-50'1_. .
<br /> -
<br /> i - TION'❑-(No septic 1yste-M e-fm+ttedcif public sewer is
<br /> `TYPE OF SEPTIC WORK: NEW
<br /> INSTALLATION ❑ +`REPAIRIADDITION'❑ DESTRUC
<br /> .._ _ � ;.r , _} _ _ _6Vailable within'200'feet.).
<br /> l Installation vuill serve: ` Res+dence Commercial Oter EA, „w _ _ . _ ., j, . f._Number of liking units: 'Numberof bedrooms
<br /> - �r-Charantarof soil to a depth-of 3 feet. l ire'" - "� '� `" 2 — s Water'ta0e`dep6'
<br /> SEPTIC.TANK _ i.Ype/Mfg �`- y �' r.. _ Capadty [L Na: Compartments I !
<br /> # I rt It s
<br /> PKG. TREATMENT PLT:❑ i Dist�nee to nearest Weill F undatlon_ /b�.,P 'Method of Disposal i
<br /> l i �r f
<br /> r roperty Llne
<br /> iV
<br /> 1LEACHING LINE I� �No"iii Length of hn2s d `'� ! Total length/sae dA�
<br /> __i_1-
<br /> FILTER'BED--;' "�❑-'�Dis,
<br /> tarice'fo nearest.. -^ ";Wetk� � Foundation "��""' ""'�roperty tine�"1-- ""�I"
<br /> I - {
<br /> r 1 - �� � � k � i i I
<br /> L_
<br /> SEEPAGE PITS `E Depth i Size c Number -
<br /> :i
<br /> E
<br /> ' _ IttI
<br /> Prop -tine---4---1-`
<br /> ISCMPS DistWell Fbundationi .{,_ artyance,to-nearest
<br /> DISPOSAL
<br /> ;
<br /> PONDS 1❑ �E 1 i ! i I I i i '•�
<br /> 1 hereby certify that;I have prepared this application an$that the iwork'will be done in'accordance wRh San Joequln county ordinarices,;state laws and
<br /> Horne ow + _;.-_..__ €- - a_
<br /> �. .. --1 rules and-,regulation's•of-the San-,Jo aquin Local-Health Distract^ _._ _. �_ .. -._,_ ��,, _- o
<br /> owner or licensed agent's signature ce�tifies the following:"'I certify that in the performance of the work for which this permit is issued!I shall not
<br /> }- ;employ any-person in such-mannerlas-to;become•subject-to-workman's compensation laws of Califom a.' Gontrctoris hiring or sub contracting signature
<br /> certifies the following•"I,ce that in the performance bf the work for which thislperm+t is issued,I shell emplo persons subject to workman's compensa'
<br /> }--�A�tionjlaws af•Cali# pa. ' � 7 • _,
<br /> (The applicant` us , all for I requir inspections. Complete drawing:on reverse side
<br /> f
<br /> , I� ; Date: I
<br /> Signed i 1-- ��
<br /> Title
<br /> i ... .:l. DEPARTM N USE ONLY I i .� { i
<br /> �nlbw C 1 I
<br /> i Application Accepted by `F .r. Date s3 r �Y S� Area d�
<br /> _._ ...- i r final Ins coon b ate
<br /> Pit or Grout Inspection by ate pe Y
<br /> ' r 1 ..__ -..:, ....�.- 1... .., J. .....�.....�• ;..tea._,.. _M...1, s
<br /> Additional Comments: r
<br /> s �
<br /> _,--.i-❑ Stk -4566781- H� L6di-3W-•3621--- ' -li-Mantece 8?3'-71a---t ❑Trac 835.6385
<br /> }' Applicant'- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave P.O. Box 20M Stk.,, CA JM`l
<br /> -.,.;..... -., i ._i...r_.i ., .�-...ice ._ a --i.-. -..w. _ ,-. ._... .....- f_ .,..,' ._._ - -.c--i-• _-I�.?' - ,.... ,_ h GIC .:_� �_..�
<br /> } FEET......._ _ - ..J. .
<br /> r
<br /> }INFO l 4IV10iCINT DUE I EIMOUN7 REMI?TEa SASH RECEIVED BY PATE PEFiM� ;
<br /> '_,a.,.� � j__.,..� :�_ ...-�_ _.---'- � !^---' •- - -fir �y.. - ., j -'^i _ _ �' ....i» ' - -j_.._a_ y
<br /> �+ EH 13-24(REV 101631
<br /> EH 1428 , i -
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