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APPLICATION FOR PERMIT <br /> SAN JOAQUI[iLOCAL HEALTH DISTRICT <br /> ' <br /> 1601 E., HAZELTON AVE., STOCKTON, CA <br /> Telephone-1209) 4613-6761 <br /> PERMIT EXPIRESLJ:YEAR FROMz DATE ISSUED <br /> (Complete m'Triplicate) <br /> ;j IL to zr K, a t: <br /> Application is hereby made to the San Joaquin Local Health District fora permit to—oonstruct an&or install the work herein described,This application is <br /> made in compliance with San Joaquin ounty0rdinanmNo.549forwwagoOFNo. 1862 for well/pump and the Rules and Iliedulations of the San Joaquin <br /> Local Health District. 1v t',� .1 zl <br /> a t. ` <br /> 11th So .ov&; k <br /> Job Address CityLot Size PM <br /> -,, M 'zyn lisaoiq ;x, <br /> 31 <br /> .Owner's Namea&x Phone <br /> gontFaCt Address Ro. �0 Yz_vz License No&9_ff12_2& .PhOZLLS_105_ <br /> , 4"J64ca—r-l—ri <br /> TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT 0 DESTRUCTION [I <br /> I PUMP INSTALLATION C1 SYSTEM REPAIR 0 OTHER Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD._ PROP. LINE <br /> r I FOUNDATIbN — AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> iINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial [3 Open Bottom 0 Manteca Dia. of Well Excavation— Dia. of Well Casing <br /> Q Domestic/Private n Gravel Pick C1 Tracy Type of Casing Specifications <br /> E;] Public 11 Other 13 Delta Depth of Grout Seal -Type of Grout <br /> El lrrig#tlon _—Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> z <br /> Well Destruction 0 Well Diameter Sealing Material (top 50'1 <br /> Affij, Depth I Filler Material(Below 50') <br /> YPMOF SEPTIC WORK: NEW INSTALLATION 0 EPA /ADDITION 0 DESTRUCTION El (No septic system permitted if public sewer is <br /> available within 200'feet.) <br /> Iiiation will serve: Residence Commercial— Other <br /> NuAber of living units: _/__ Number of moms -ii- <br /> 26 <br /> F7 <br /> Character of soil to a depth of 3 feed —Water table depth <br /> SEPTItEr <br /> ,TANK Type/h Capac =�­1 No. Compartments <br /> PKG. tEATMENT PLT: il I . /.-- <br /> t Method of Di9posal <br /> Distancili,to biarbif.A%4*g1l I�IP74: Foundation ZZ�41 Property Line <br /> LEACHING LINE -1,NP<No. & LAg Total leAgth/tsize A <br /> RfE41ED -iOxb!Z�ical() Foundation <br /> SEEPAGE PITS 0 DOPAII i, size N <br /> OMpiEl Dk4tance Ito nearest: 'well Foundation Property Line <br /> DISPOSAL P INDS El iv <br /> t hereby certify that I have pre -ted thii application�aihcl.that the work will 16Cclone in accordance with-San-Joaquin-county-ordinancei, state lam,and <br /> iujos and regulations of the Sfi; Joaquin Local Heolth'Disfrict. -1<1 1,k I /, <br /> - <br /> Home owner or licensed agent's signature certifies the following; "I certify.Whet <br /> in the performance of the work for Le�two permit it issued, I shall no <br /> 6(nPI6y!any person in such'.ni.annar as to,bebome subject to workman's compensation W;k�&f I 611fonria."Contracl;8A hiring or sub-Antracting signature' � <br /> derti Ise the follcmirig:"I cirVY that in performance of the work 16r which-this 156mi6is'essiuJidlZaboll employ persons au to"rondn's compensa- <br /> tion laws of California �.t 4— 1 <br /> 11 fo ;-ill r uired Inspections. Complete drawing'onlrelverse I a. er4 <br /> S AIN Date: <br /> FOR DEP ENT USE ONLY <br /> Application Accepted by Z.4 Data 7L <br /> 1 1 <br /> Pit or Grout Inspection Date Final In'spection by <br /> I <br /> ;kdeliflomil Comments: <br /> (2 Stk; 468-0781 [I Lodi 389.3821 11 Manteca 823-7104 0❑Tracy SW6386 <br /> Applicant- Return all copies to; EnviroArriental Health Permit/Services 1601 E. Hat.ofton Ave., P 0. Box 2009, Stilt., CA 95201 <br /> FEEAMOUNT REMITTED KS* <br /> INFO AMOUNTDUE4 I CCA H RECEIVED BY DATE PERMIT'NO. <br /> /85) AS& <br /> EH ill- 26 <br /> V <br />