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rZ <br /> +' <: APPLICATION POR,PERMIT' <br /> SAN JOAQU;N LOCAL HEALIH'DISTRiCT p 7 ti <br /> 1601 E. HAZELTON AVE., ST XKTON CA PERMIT NO.S �"' <br /> �.. <br /> Telephone (209) 466.6781 u, <br /> y�fP <br /> ..�- DATE ISSUED'Z—�^Ce—'L-+ <br /> ` • ��~ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) , <br /> a <br /> Application 1% hereby mad 'to tht,5ai�.ksaquin Local Health District for a permit to construct ant/or install the cork herein <br /> ! described, This application is nwdeyip'•eompliance with San Joaquin County Ordinance No. 549 for sewage or No 1862 for well/Dump. ;Y <br /> and.the Rul�esgand(R cal tons f+t 5 n Joaquin oc Heelth District. <br /> Job Addres SuDdlvisl0n Name <br /> hon <br /> Orner's hand` ? Address Phone "�f�+�5�� <br /> �d <br /> cense No. �{7 ft 2 Z tit 4 -' <br /> ?. Contractor's Nane� + ;^ <br /> ` TYPE OF WELL/PLP1P WORK:, NEN WEL WELL REPLACEMENT [] <br /> DESTRUCTION <br /> PlA1P 1NSTALLAON`[] SYSTEM REPAIR OTHER U - <br /> t <br /> DISPOSAL FLD. PROP. L5 ¢ i <br /> DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES <br /> s" FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SLWS " <br /> ¢ r INTENDED USE TY3E OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATiOib <br /> 1 Industrial.' Open Bottom Q Manteca Dia. of Well Excavation e jai <br /> xkr i':�" Dia. of Well Casin <br /> LJ Ooorstic/Pv ivate 0 Gravel Pack (�TracY a i tivt ., <br /> (� <br /> Public <br /> Other " Delta ! x' ✓t <br /> [] Type of Casing ¢ tz <br /> Apprcx. East <br /> Irrigation' ern SpecfflcatlDns <br /> {` Depth <br /> Cathodic Protection Depth cf Grout Seal <br /> rarna. �a ., r f <br /> 117 Geophysical Type of Grqut • r= Pyr- - �{: <br /> []Other Surface Seal Installed by x '« <br /> Repair Work-Done[] Type of Pump H P State Mork Done <br /> Well Destruction ❑ We11-01ameter Sealing•Material (top 50') <br /> Depth Filler Material;,(Below 50') <br /> TYPE OF;SEPi1C WORK INSTALLATION REPAIR/ADDITIOtI (Na septic tank or seepage pit permitted if public s xr <br /> available within 200 feat. 'w <br /> ' Installation will serve: Residence 0000,Coneaercial _.Other C <br /> ` hwber,of 1IVfng units: Nuvber of bed ooms, Lot size Mater [able depth <br /> 4 t <br /> F} Character of,soil to,a depth of 3 feet:, <br /> " . Compartments <br /> TANK Type/Mtg <br /> Capacity ' No <br /> «1 SEPTIC _ <br /> rOpacity 1llethod of Disposal <br /> • PKG.•TREATMENT PLT.• Type/Mfg <br /> SEWAGE9SYSTEM Q_ .Distance to.nearest Well- -Foundation Property.Line <br /> «rIDESTRUCTION <br /> L2 +'No •B:Lrngth of,-lines Total length/size ' <br /> LEACHING LINE R <br /> FILTER BED Distance to nearest: .Well Foundation Property Line <br /> SEEPAGE PI <br /> is '-Depth - %� _, Size _ 'b}'•.. 0 if„ <br /> Numbe <br /> SIAtPS TY • U Distance to nearest: Ciel l a' -Foundation Property Line <br /> D I SPOSAL*P011DS <br /> I lwrebyftertlfy that I have prepared�,this;-applitation and that the work will be done in accordance with San Joaquin county. <br /> ordinallCss:�state.laws,:and rules and regulalttonsof:the San Joaquin Local Health District.. <br /> ifoaeioi(n!r or aicensed agent's signatureFllt�fieSIthe'following: '1 certify that in the performance of'tte cork for Which;this' <br /> u4 <br /> n per�itpeir or1ic I.shall not enploy anY Persdl�ln-Such manner as to become subject to workman compensation la►r of Culifernia Y <br /> Contract <br /> following: "I certify,that in the performance of,the wort for which <br /> or'sshiring orsub-contracting:Sigt <br /> Chit'permit.is`issued,'1"shall employ persons subject ma <br /> to workman's canpensation laws of California." �« <br /> ltca nusL sal n l;requlred'tnspections: Complete drawing on rev e �fde. « <br /> int app ate: <br /> Signed X <br /> Title:, -- <br /> , <br /> a " ! <br /> DEPARTMENT USE ONLY <br /> . D <br /> a +., St <br /> k 466-ti7BlR• k:?� ` <br /> A lice ton Accepted by: Area (- <br /> PP, ( Lodi 369-362 <br /> " Additional Coeanents <br /> :`* > Date J Manteca 823-7104 a, <br /> fit P1t or Grout Inspectfon..b ti <br /> "' Date _�'/G�1STJ ❑ .Tracy 835-6s85 w f yd'. <br /> Final Inspettion`by v ` <br /> 9ypl(cant -.Raturn all copies o:;,Envlron!n?eLe 'Health Plraitt/ServlCes 1601'E. Hazelton Ave.. P.O: Box 2009 Stk., A 920 JY '/*+' <br /> r PERMIT NO- Y <br /> FEF SASE "AMOUNT:'DUE _ An7,INT REI ITTEO RECEIVED DY DATE <br /> 1 <br /> INFO. -- I�i '•� tr. <br /> IU/12,50C ? j <br /> '7 E1i.13-2« REV, lU/82 <br /> 14-26 <br />