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<br /> APPLI6A T1 FOR PERNuf
<br /> pAam L'
<br /> .,7SAN jLOCAL HE. ALTH,DISTRICT
<br /> 160l-,E. HAZELTONAVL, STOCKTON, 64:
<br /> Telepho6e (209).466-6781
<br /> �,PERMIT IEXPIR!"ES.1YEAR FROM.DATE ISSUED
<br /> (COMP16te in,Triplicate) 0.'
<br /> Application is hereby.made to the gan Joaquin Local Health District for a permit to construct and/or install the woik�herein described.This applicati6n is
<br /> in compliarice with'San.tloaquin County Ordinance No.549 for sewage or No. 1852 for,%Well/pump and'the RUleiand Regulations of thei'San
<br /> , U Joaquin
<br /> Lal Health District.
<br /> b Addr Ci
<br /> Lot he
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<br /> V,
<br /> to,
<br /> d a
<br /> O;iiiifl. Name "Of Adore
<br /> P on
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<br /> Cortracto
<br /> sam
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<br /> I hA, . o
<br /> OA r
<br /> TYPE F WELL/PUMP: I NEW WELL 0 WELL-REPLACEMENT-171IE
<br /> DESTRUCTION 11
<br /> PUMP.'YNSTALLATION 0SYSTtM REPAIRL'L]
<br /> OTHER El.
<br /> DISTANCETONEAI4EST:'1S'EPTIC TANK SEWER LINESL DISPOSAL FLD.',- F PROP,-LINE'
<br /> �40UNDAitON AGRICULTURE WELL, OTHER WELLPIT'S/SUMPS
<br /> INTENDED USE s'TYPE OF WELL PROBLEM AREA
<br /> CONSTRUCTION SPECIFICATION
<br /> [1 Open-.113ottc 'Dii, 6f Well E�� vation -Wet Casin
<br /> Indusi )tn El MahtGa:
<br /> n6l ca Dia. of I
<br /> 6fi
<br /> 171'.Domestic/Private 0 G rav 6f Ca SPecfficalidn;
<br /> Gravel{Pack C _Tracy Type
<br /> El Public f]-Other •A' O=Delta Depth of Grout Seal
<br /> TypeofGrout'
<br /> 6 Irrigation. _AppjoX.!Depth' 6 Eastern ,"Surface Seal Installed by A.
<br /> RepairWork bone E1 Type'of1purrio"
<br /> Statim D6no`1 r
<br /> estruc
<br /> Wall D tio67 El Well'Diametersling Material teri,l (to. p-i�)
<br /> DCp Filler (Below 50').
<br /> ZZ7;�� . M
<br /> TYPE-OF SEPTIC WORK: NEW INSTALLATION qr,:REPAIR/ADDITION 0 DESTRUCTION-'LJ 4No septic system permitted-if public sewer is
<br /> availabie w4iin:200 feet.)
<br /> Installation vvJlI'serve:,,,". a ence Commercial Other" iZ
<br /> IT Number of living units: amber,of be ooms-s'
<br /> Chapcter of soil to a,clepth of3feetA Water table depth
<br /> -,All, -1Y
<br /> SEPTIC TANK D', Tjpe/Mfg Capacity No' Compartments,
<br /> PKG. TREA-tMENT 13LT. d, 49
<br /> Method of Disposal -
<br /> Distance io'nearest: We Fo' d'ation JJ�0' Pfoperty Line
<br /> un
<br /> ?LEACHING LINE. D2. No &,Lenjith IrS.
<br /> _TptaI1ength/sizd_
<br /> `j`FILTER,.BED L2'.' Distance to nearest: Well Foundation Pro rt� Lin�
<br /> C2
<br /> SEEPAGE PITS Depth 'un4ber t
<br /> . N
<br /> SUMP 0DIstanceio near It, 11 Foundation Pr party
<br /> bine`' ED
<br /> DISPOSAL PONDS
<br /> ILI
<br /> r.
<br /> I hereby,certify,that I hav≺parod this applicaiion and that thelwork will be done'in;ac�drdance'vWth San'.Joaqui;
<br /> .rules.and reg6lations'.of"the Sah Joaq6in'Locial Health District n county ordinances-,--state laws, and
<br /> w ice sed ,I Corti
<br /> ,Horne owner or 11 n agent I signature d�ilifies the'fo'llo'wirig: at in:the:
<br /> fy;th pgrfoi"nce of.the work:for whic.h-this'permit is issued, I shall not
<br /> -'employ any pemoh in such'manner as to Wecome subject-to workman''s o6mpens'ation laws of California:."bontrad.toes hiring or sub-contracting signature
<br /> certifies the.followi6l�"f6ertify ihai'in the poko.rmancelof the work formkhj6h this permit is issued, I shall employ pbrsons:su bject to workman's compensa-
<br /> tion laws of California."
<br /> 1.r ''red 6m
<br /> applicant
<br /> MUSi_l�all for 4'. rawin
<br /> The ap�u inspection C p ate,d side
<br /> 77
<br /> Signed
<br /> X Title:a, Daie:'
<br /> FOR DEPARTMENT USE
<br /> ONLY,
<br /> Z
<br /> ZIP=
<br /> fiAccepted by
<br /> Applic. Date rea
<br /> r rout n ion by ate
<br /> t
<br /> Additional 6brinmeints-.
<br /> 0-Stk 466-Ml 110 Lodi t369-3521 0 Manteca Z23-7104
<br /> Tracy ',.835-6385
<br /> Date:.
<br /> a,
<br /> �wutn I,
<br /> Health Permit/Srvi,e�6 Ave., P.O. Box 2009,-.Stk., CA 95201Applicant Return all copi6s to: Environmental
<br /> ,Hazelton
<br /> FEE AMOUNT DUE' AMOUNT REMITTED CK It
<br /> fiECEIWDI
<br /> INFO BY� DATE PE
<br /> CASH
<br /> +EH13-24(REV.10183).
<br /> (70
<br />
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