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<br /> APPL'CATION FOR PER41T
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<br /> SAN:JOAQI,>', U)CAL HEALIri :ISTRiCT 1 t yR tom"
<br /> 1601 E: HAZELTON AVE_ S70EXTON, CA ➢ERMII NO '
<br /> ' Telephone (209) 466.6781
<br /> 14 21
<br /> 4 PERMIT EXPIRES 1"YEAR FRO, OATS ISStiEA'
<br /> Ls
<br /> DATE ISSUED
<br /> iComplate-in Triplidtf)
<br /> si Applitdtior is hereby made to the San Joaquin Local'Health Distritt for a permit t6 conitrkt and/or gni tell tate work herein
<br /> described.' Th is`:application is made in compliance with San Joaq in County Ordinance No.-MO for ►prage or N4, 1562 fOn'ivali plinip,
<br /> and the"Rules r' Req Dations of.the-San Joaquin"Local Heait trio.
<br /> Jab Address" S `7_ w" L/A/N 1!_: vision Name '
<br /> i Owner s:Name M R5 Ndl71 41T 1 ` ddress' S RSr►1_
<br /> ' Contractors Name P'h "'CARb'I a License No,; y 39! ,;�;Phone �f3 ; .S
<br /> "TYPE OF t:ELL/PUMP WORK NEW WELL. WELL REPLACEMENT, �` DEST�iDCTION, -
<br /> r PUMP INSTALLATION (�- SYSTEM REPAIR
<br /> DISTANCE TO NEAREST :SEPTIC TANK" SEWER LINES. 015hOSAL FLD �PRpP
<br /> FOUNDATION..` AGRICULTURE WELL OTHER:WELI ��,pf1S15UMFSr :
<br /> 1 a -
<br /> ° r� INTE1iDED USE. , TYPE OF WELL PROBLEM AREA C villi} TTON SP1C_if1CATION5
<br /> ti+' ,3 �A ndostrial U,Open Bottom Q Manteca via..Of Well Ucavation, "
<br /> Mr.rn
<br /> , { Domestic/Private j 0 Gravel Pack' [}Tracy Dia.,.of tiitll Casing
<br /> °14r Public [j Other []Delta r e
<br /> h< _ Type of Casing ` 4r
<br /> 'i lrri anon ' rox. Eastern wr
<br /> Depth. Specifications #
<br /> CathoETC ProtectionDepth of Grout Seal
<br /> 0 Geophysical i' ? �
<br /> r :type 0. Grout �e
<br /> j�Other : Surface Seal Installed by
<br /> f Repair Work Done �] ,Type of Pump H P State Work Done
<br /> : „ - -
<br /> Well Destruction [� Wel l`.Diameter: Sealing Material {top 50') in rx �
<br /> ' Depth Filler Material {grtew 50 ) y s f ate, t
<br /> � t h S
<br /> t TYPE OF,SEPTIC WORK- NEW:IH5TALLATION rl', REPAIR/ADGITIOii ,�;(Np,deptic tank or seepage pif.permitt2d if putiTlctsewe
<br /> rF e'
<br /> Within 200 feet
<br /> ri Installation wll"1 serve Residence Commercial Other ` ,
<br /> Number of living units.." �_----`Number of bedroomz" �� Lot, Size ' �`' NQ'�f
<br /> rC Character Of soil to a depth of-3-feet: Lne-AMy Water table depth �� a
<br /> r" SEPTIC!-TAN K �j Type/Mfg Capacity NO C9mpartmentsi' pr.
<br /> PKG TREATMENT PLT.r Type/Mfg, Capacity Method of Disposal
<br /> t ¢ r SEWAGE.SYSTFM Distance.to nearestWell Foundation Property line ~ r� Gb
<br /> o� DESTRUCTION rx r ' r
<br /> ifACHING CIhE a(J No Length of.Un s + Total letigth/size
<br /> ^- ,'
<br /> FILTER SED Distance to nearest; Well �0l7 Foundation. /0 Property Line
<br /> r °SEEPAGE PITS Depth,` Size, Number
<br /> SUMPS 3' LJ Distanceto nearest-.. Weil Foundation Proserty,tine ' T a
<br /> "sY
<br /> DISPOSAL6:15S
<br /> I hereby_2erttfy"_that,]".have prepared thls`applr anon and that the work will be done in accordance with Syn J`aaquincountya r
<br /> ordinances, state;laws,'and:rules and regulations of:'the.San.Joaquin.Local Health District �s n
<br /> Hare-owner or Licensed agent's signature cert i f 4 es:.the following: 11 certify that in.the.performance.of, he work,for which this 7
<br /> $ permit;is;issued,,,j'shall not employ.any person in,such manner as to become subject to workman§,compensation laws,of Cal, Ornia F' .
<br /> Contractor s hirin'� or, sub-contracting signaturii certifics:ihe"followinji. "t certify that in'the performance of;the wdrk:for wife '
<br /> +."this permit is ,sued I;shall employ Persons subject to workman's compensation laws of.California 4
<br /> 4The applicar t_call for,all requir inspections;, Complete drawing on reverse side: �� �kk ° 45 r
<br /> Signec�rf .' Ll+, �{ Title: �JWI(CiL
<br /> PARTMEN F ONLY �_
<br /> w APG11cation.�AccFpted by _ yy 66 -
<br /> i 77 7777
<br /> Additional..:-Caarents [ Lodi � 69}36�21� P 'F {
<br /> Pit or Granit Ins?action t Acte } Manteca 823 7104 VSD
<br /> 2 Final lrspec ion by � �� �iLLr Ddtc Tracy
<br /> A �icant,'._.Return,all-c' irs.to.'".Env}rain . HSa:;th f2rmit/Sewice3 1601E . Hazelton Ave Box 2005 Stk'�CAs4520 ,
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<br /> IEE: I .'BASE, MODUT DUE NlX1rrT REM TTED r RECCIVEO SY DATE e.>PFRMITyNO
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<br /> f INFO, '. �'�3
<br /> { t`+ ]3 za' REV.,i,^,81 1`0132 500 rs '
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