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F IL E 'GOP �.
<br /> xfi APPLICATION FOR PERMIT . `
<br /> {!` SAN JOAQUIN LOCAL HEALTH DISTRICT -- •" £ ,
<br /> 16D1 E. HAZEL—ION AVE., STUCICTON, CA
<br /> f Telephone (209) 466-6781 0 r.
<br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED
<br /> f x omplete in Triplicate, T12 VA,
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<br /> r,,� Applitatian is hereby made to the Son Joaquin Local Health District for a permit to construct and/or install the work herein described.This applicationiB 1r 1
<br /> Rw � made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules end Reyulatiorrs c the San Joaquin.� r<;V 1 atr
<br /> ;: 4' Local Health District.
<br /> s <'Job Address 3h'
<br /> r
<br /> CJ>�+ s�_4 4S-�T Wt a t 6" i2c _ City TA1 Lot S14C
<br /> ae 'i PM
<br /> Owner's Name i—Wd _ Sd+�__ Phone _., st_'7SL
<br /> 5A-
<br /> 47.
<br /> '5 ' ^Ad rasa E
<br /> �r t Contractor V#A& Address _ -.WAIF L—W License No.3AN14 Phore )
<br /> K7'- "TTYPE OF-WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION O
<br /> aydi a PUMP rNSTALLATION'❑' SYSTEM REPAIR ❑ OTHER p • p
<br /> y t rD157ANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.illlE
<br /> V' r "* FOUNDATION _AGRICULTURE WELL OTHER WELL PITS/SU dP5 ~ r nl
<br /> ^, &`.: - iNTrNDED USE - TYPE OF WELL PROBLEMAREA ` CONSTRUCTION SPECIFICATIONS
<br /> 241.
<br /> ❑Industrial ❑Opan Bottom ' ❑Manteca Dia.of Weli ExcavationOle rr Wel Geeing ° "Domeatic'Prlvata ❑Gravel Pack ❑Trecy Type of Ct>4 ngSpfciiy '❑
<br /> PuT� �60,
<br /> J 344 ]Other- 0 Delta th of Grout Seas ixpt
<br /> �' f � Irrigation, ----Approx. Depth ❑ Eastern . Surface Seal Installed by r
<br /> rx� Repair Work Dore ;❑.' Typo of Pump" H.P. State Work Done °fs i [
<br /> Well Destruction ; "O Well D!ameter Sealing Material(top 50'1
<br /> iA�-efw-' `,.fit} - -�z.:. ='�," :3 Depth, -.i., ,. :7: r ..Y:cF,k ,,• r � `
<br /> '
<br /> a j Filler Material f6elow 50'i
<br /> y''' '�y,TYPE OF SEPTIC WORK NEW INSTALLATIGN� REPAIRIADDITION Q DESTRUCTION 0 (No septic aystem permitted If public sewer isA*� f At
<br /> , ,. feet.),,.
<br /> 4� au�r 1 r available within 20D
<br /> a i Installation will serve Restdenca '.� Commertial a Other /✓L/ri�7F� yD ft r rxr7 LaE 4' yt
<br /> y 5
<br /> Numb♦f - s r - - t *-.r a z ..: a eKyN f C 75.,r go'T,r i" x:e •r
<br /> s er Of living units: .Number of bedrooms
<br /> x ..� xh Character.of soil to,a depth of 3 fset: C Waier'teble depth v''s0' " ' AA
<br /> i ?SEPTIC TANK " Type/Mfg r�I.•�apatit /J`�� £ ""�-� r4� t
<br /> - ;r y No Compartmental + xre x
<br /> s;PKG TREATMENT PLT ❑'ZS;''t 4,. ,, - ' F `' Method of D+aposal 14r
<br /> Distance to nearest: ^ "Wail r �2 ✓> y r F Y �/` r r
<br /> M _ Foundation _ Property Line jra5
<br /> i'c �•Fk
<br /> f , i r ,w )a �, x�,.Fk r � x;
<br /> r LEACHING LINE 1 +"1��';No, &Length of lines 'Total length/su a ° )_11
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<br /> FILTER BED� � , �9"v C7 ;.Diatanca.to,nesreat: Wall/sem.::.Foundation`;��J ProLin-
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<br /> tt "T PertY -;{.•"�. , ,h �
<br /> k UNt. r 4x J f {N� (✓
<br /> ,SEEPAGE PlT5 ' .� 1 Depth 29 ._3A t
<br /> t! F Number
<br /> "J5MP5ik d Well 1,00 Foundation Pr
<br /> #Distance to nearesopertyrLine ,S a w� , _ •.k.
<br /> DISPOSAL'PONO5,�
<br /> ❑ s r
<br /> r, l herby.certify that I ti:tve prepared.thia application and that"the work will be done in accordance with San Joagwn county ordinances state laws and
<br /> E. rules and:reguletwiys of the'San Joaquin Local Health District.
<br /> ' Hoe gwnar.4 Goinsed agent's signature certifies the foQoMng I tart%fy that in the performance of the wort:for which this permit is issued,'I ah iQ not'%�
<br /> T memploy arty person In such manner as to become subject to workman's compensation larva of California."Contractoes hiring or aukcontracting signature (
<br /> r }rcertJfkrs the following:'1 certlty that In the performance of tho work for which this permit is issued,I shall employ persona subject to workman s comkensa ri
<br /> yy�� tion taws of California. ,y', - ,Y ,', < '!'�'� �"r ` -_` r
<br /> r+7• tYak:.er'+...... J. ! �,..+
<br /> epplkant m call for required inspections.Co pie, drawing on reverse side :i•' I z= `
<br /> } l i Slgrred rde: Dale:
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<br /> OR DEPARTMENT USE ONLY
<br /> t $ � Applitatlon'Accapted"b r Date aY�'�%5- r Area
<br /> 9,
<br /> `, r .;
<br /> o'{�'5 � Grout lnspecuon by Dam Final Inspection Date
<br /> y�yy '�Mw"��'
<br /> ;Additi0}101-Comments
<br /> ��► w��ri,�"I7 Stec-465-8781- k.v'❑Lodi"3M-MI ""'C]Mantua '87104 Q Tracy »
<br /> Appiwm Wm
<br /> lReturn all copies :Environmental Health Aarrnit/Serveces,1601 E.Hazelton Ave., P.O. Box 20Q9 5;k:CA 95201
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<br /> +a,� b MY FNFo AMOUNT DUE AMOUIOT REMITTED GSH RECEIVED BY -:-DATE PERMIT NO
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