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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTU y, CA Telephone (209) 466.6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) rk d This de "tion is cati�is hereby will Son Joaquin the Sar Crx�i Jtnty Ordinauin Local nce No 549ealth r1or sewage or ict for 0 permit No. 1862 lot well pump and 11 c Ru es and herein Regulations of the Son Joaquin ance Local Health District. [ o 1 Ot F- AL 11.)u Lot!5� Lot Sire PM '-- Job Address -- - n_ ��&1 pp _- Address Owner's Name - �-VALA-`'v sur"'^1'S�1. C�-{��•�' ��+,p��(//pp�� -�J� 1/ Addw--V-1/��iJ..L1�tLu?_l cense No. _---------_ PnonetS`l_L ALX �/� Contracts �. TYPE OF WELL/PUMP: NEW WELL 1/ WELL REPLACEMENT ❑ DESTRUCTION u PUMP INSTALLATION Cl SYSTEM REPAIR Cl OTHER 0 iSEWER LINES DISPOSAL FLD._ PROP. LINE DISTANCE TO NEAHEST: SEPTIC TANK __. - -- PITS/SUMPS J FOUNDATION ___.--_._- AGRICULTURE WELL OTHFR WELL INTENCEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ Open poltom t I Manteca Dia.of weill Excavation._&111 ;.11--- Dia•of Well Casing ��- U Industr..tl , T of Caern -M..._� P�.�es�...._ Specifications n Domestic/Private Gravel Paco Tracv Type Sl q tr�l� f✓p�rt.}rc�'{pfltK4,1a1� 1%./Otherflans [1rp,•h of Grout Sral .i.�. . __-- Type of GfOUI 5QY * t !Irngattnn W F-1J W Approx. Det--h I I Ea..-,win Surface:;^:!tnstallud by—..—--------- -- Repair Work Done I 1 Type of Pump -_. H State Work Gone __ - ----- ' Wolf Destruction (1 Well Diameter __ Sealing Material(lop 50'I -_ —--- - - - -- - ' Fillet Maternal(Below 50'1 _ ---- -- -- TYPE OF SEPTIC WORK: NEW INSTALLATION I i-1111•AIRrADO1T10N I I DESIlluclION I 1 (No seplrt sys,"n, parmdtivt if public seam rs available within 700 feet 1 ` Installation will serve: Residence— Commerc al Uthar Number of Irving writs: __.- Number of bedrooms Character of soil ,a depth of 3 feet Water table.depth Capacity SEPTIC TANK (I Type/Mfg ___ __----- No. Comoartmrw-ts f - - - t PKG. TREATMENT PLT. 1 Method of Dispo \ sal Distance to nearest: Well Foundation -.-----�- Protwrty Lina - \\.'• f •� i LSACHING LINE -__1.1 No. 6 Length of lines FILTER BED i I Dist.-.,cot to nearait: Well Fnundatton Properly Line - - -- -----— --- - SEEPAGE PITS I I Depth SUMPS I 1 nlstance to nearest: Wall Fo,,ndaitnn Property Line i DISPOSAL PONDS I 1 I hereby certify that I have propo nil thus application and that Ihr wnrk will he done to accor,lanc r with :i»n Joanum county onLnancrs, state Isws, end rules and regulations of the Fan Joaquin Local Hee111, U 4;ncl. { Home owner or licensed a{rd's signature certilies the following: "I certify that In the oerformance of the work for which this permit is issued, I shall not all y any person in such nnnnof as'n become subject to workman's compar-tion laws of California 'Contractor's hiring or scat)contracting signature Certifies the following:"I certify that in the performance ilf the work for which this permit is issued.I shall employ persons subject to workman's compensa tion laws of California.- Tl.a applicant 1st l f re a C speeti complete drawing on reverse sad Signed _ -� ..... Titb: -T�flf-G�C�I� ---- - .. -- Date: FOR DEPARTMENT USE ONLY hate ---- Area _. . Application Acrepted by _ --- - _ /I/ 1!fi[- _ p •., _/J Final In,pechon Date Pit or Grout Inspection by /y•r 77 IDA- Additional Commamr. —(— f I SO, 4CA 6781 Ul Lafi '3�3671 ❑Manteca 823.7104 O Tracy 836.8385 Applicant • Neturn an copies to, Environmental aoe'th Permit/Service 1601 E. Hazelton Ave., P.O. Hox 2009, Stk., CA 95201 rrE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ATE PERMIT NOZD [H I.711 _-