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r APPLICATION fOR PERMIT ' <br /> SAN,J.OAQUIN LOCAL HEALTH DISTRICT <br /> v. iBOt FiAZELTOhf AVE., STQCIGTGN::.CA g <br /> Tolophone (239)°4666781 , <br /> PE•FMIT EXPIRES !.YEAR FROM DATE..ISSUED u <br /> (Complete in Triplicate) <br /> Appikation is hereby made to the San Joaquin Local Health.O'atrkt!ar a permit io construct:nndIlii install the work herein dexrlbed.Th1s'aPp �n i+ s <br /> s" rrlade:in Compliance with Sari Joaquin County Ordirlarlae.Nc,60 for sewage or No,IB82 for Well/Pump and the RuieS and Regulations of the Sen.FeeQutn t <br /> Local Health District. 3- <br /> _ r <br /> Z City :i l t` tot Rize ` -41 PM y <br /> Job Address Phone <br /> IM L -Address k: <br /> pwrie�s:Name <br /> r <br /> Phone <br /> Cdntractofs Name °License NO. 1 <br /> WELL REP <br /> Q DESTRUCTION <br /> TYPE OF WELL,PUhTP NEW WELL C7. +` <br /> PUMP INSTALLATION 't7 <br /> SYSTEM'REPAtR Cl-. 61-ITER C3 <br /> DISTANCE TO NEAREST: SEPTICTANK <br /> SEWER:LINES DISROSAL FLa. PROP LINT= f <br /> T FOt1A1DAT10N AGRICULTUREWELL OTHER WELL ptTSISUMFS <br /> _ - •" hM. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA- CaNSTRUCTION SPECIFICATIONS <br /> fN iEN <br /> W Dia.of Weil Excavation, �� •OC Casing T- <br /> C7 Industrial C7 Oven Bottom C1 Manteca, Speoifieatiora { <br /> f p,Domesticiprivate ❑Gravel Pack 0 TTSCY Typaof Casing <br /> 0 Public 0 Other C1 Delta Depth of Grout Seal <br /> Type of Grout <br /> .:- �lpproz:Depth t7.Eastem Surface Seal Installed by. <br /> '' auState Work Oona <br /> H•P + <br /> Rep .Woik Done C7 Type.of Pump: <br /> Wel Destruction C3 Well Diarnetes _ Sealing Material:{top 50'1" <br /> y< <br /> Depth Filler Material(Below 50'1 # <br /> TYPEflF SEPiIG WORK: NEW_INSTALLATION C3 REPAIR/ADDITION Cx DESTRUCTION"CJ INo septic systern Pertttitted if.Pub4ic sewer is <br /> available.vvithin 206 feat.) <br /> ltis!ada[ion wA server Residence Commercial Other <br /> Num7er of.fivlrtg units Tf.. Number of bedrooms .- <br /> Water table depth " <br /> Character.of"Soa tri a depth of 3 feet �f <br /> SEPTIC TANK TypeLMfg .C, ' Capacity. NO.-Compartments <br /> Method of Dhgxisal <br /> PtcG.TREATMENT'PLT:'D <br /> Distance to nearest. Wet_�� Foundation //t_ `1f Property_ins Y <br /> Total length/siz <br /> LEACHING LENS: © No.&Length of lines _ <br /> Well Foundetk a_^'V - Petty Line <br /> FILTER BED `:Distance to nearest:' ' <br /> SEcFAGE PITS © Depth <br /> Sue 3 Number- t v <br /> I <br /> SUMPS 0 distance"to nares Wet - ---.— <br /> Foundat on Property Lina: ' <br /> D15P! OSAL FONDS C3 <br /> :hereby certify that 1".have prepared this application and that the woA will be dono in accordance with San Joaquin county o dinaticee.;state lavas and <br /> rules and regulations of the Sen Joaquin Loin Health District. <br /> Home o+vrleror licensed agenCs signature 6erMmtt the following:"'1 certify that in the perforn^.ance of the viork for which this permit is"lstuedI 1 shall net <br /> tmdoY ariy,peraon In with manner as to become subject to"workman s compensation laws of California.-'Contractor's hiring or wb eanttactlrg signature <br /> cartifiea theforo+ rg: <br /> 1'1 caroti'that in'the performance of the work for which this permit h issued,t shall ampioy Persons subject to workman's componsa• i - <br /> bort taws of Cel"dorrlia:' <br /> f rola.Complete drawing on reverse aide. - <br /> i• The applicant must call for rN required inspect. �y_� yjf� <br /> i Title:" Dais:TEr ir <br /> Signed w��r` e.�. � •�/,��i <br /> f FOR DEPARTMEN-.USE ONLY . <br /> Date LL_ Area <br /> ApACicatan 11 ed by iL`/ <br /> 9, ��gr/A�n�' - - Date Final Inspectionby <br /> —-+ � Data <br /> x Pit ar carotr�nspa�ro by <br /> Ut W25 <br /> r Additional CCrnnlertta. <br /> ❑Stk 486-6781 J Lodi 369-3621 CJ Manteca "823-7105 ❑Tracy 83S63a35 <br /> $ Applicant*Retum ar copies to:Emrironmental Has"Pemdt/Services 1601 E.Hazelton Ave.. P.O. Box 2009,Stk.,CA 96201 <br /> 1-FFE D AMOUNT REMITTED C'r RECEIVED BY <br /> . DATE YERMf1'ND: <br /> - INFO AMOUNT DUE <br /> Ell 13241i1LH lorell. - _. <br />