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I ' a D APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZEL T ON AVE., STOCK T ON, CA Telephone (209) 65-6781Z. PERMIT EXPIRES l YEAR FROIA DATE ISSU D (Complete in Triplicate) p 'CCrC;;� ,� Application is hereby made to the San Joaquin Lova! Health District fora permit to construct and.'or install f�wok beret es-rib �F application is made in compl;ance with San Jcaquin County Ordina ce f.o. `_�9 for Pae or No. 1362 for well:'dump and the r upas nd R tion an Joaquin Local Health vis:ricI. 150 / �f r.,s l Z]9 y„7 f (J / `s�!��9�� 195-121 -12 Job Address SE corner of Lathrop and Harlan Roads city Lathrop Lot size 1 ESA es pJ 95-121-13 Owner's Name Saye Ifart SuPermarkPte Address Miodestol — Phone (200) 5- - 95352-4278 Cp�t.'eC":Or Kra7Bn and Associ ateSdd,ess 3860__x_ Wi nP-ry Avp_ License Eio,490CIOR P.tione Q201—; , 7 1rJ TYPE OF V,'ELL,`PUI.rP: NE1'd WELL a WELL REPLACEIfE t7 _ . E7101 � TRUCTION ❑ PU1JP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER B Geotechnical DISTANCE TO NE-'REST: SEFTIC TANK 100 r SEWER LINES 50' DISPOSAL FLD. 100' PROP. LINE 50' FOUNDATION 50 AGRICULTURE WELL 100' OTHER WELL 1001 PITS/SUt4PS 100' IN7END---D USE TYPE OF WELL PROBLEM,AREA CONSTRUCTION SPECIFICATIONS ❑ Industtial N/A C Open 3ottorrNI/A ❑ Manteca N/A Dia. of Well Excavation 4 5 Dia, of Well CasingNIL Domestic Privz:e C Gravel rack L7- Tracy Type.of Casing_VA —-- Specifications N/A { F-. Public F-i Other [7 Delta Depth of Grout Seal N/A Type of Grou6 sack sand t 1 Irrigation _Apprcx. Death 1 l Eastern Surface Seal Installed by _ Repair Work Toone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Flier Material ISe€ow 501 r TYPE OF SEPTIC V.+ORK: NEW INSTALLATION I 1 REPAIRrADDITiON i 1 DESTRUCTION I I (No septic system permitted if Public sewer is N/A available within 200 feet.) Instaltat on will serve: Residence— Commercial ^ Other Number of lMng units: Number of bedrooms lzz�l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type,Mfg Capacity No. Compartments s PKG. TFEA T IJ.ENT PLT. ❑ t.;ethod of Disposal Disance to nearest: Well Foundation Property Eine LEACr'ING LINE ❑ No. & Length of lines Total length;size FILTER E;ED ❑ Distance to nearest: Well Foundation Properly Line SEEPAGE PITS 1 I 'Depth Sue Number SUIJ,PS 0 Distance to nearest: Well Foundation Properly Line DISPOSAL PONS ❑ I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Saws, and it rules and regulations of ;tie San Joaquin Local Heahh District. _ Home owner or licensed agent's signature certifies the following: -I ce;<ify that in the performance of the work for which this permit is issued, I shall not- empioy any parson in such manner as to become subject io workman's compensation taws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa• ticn tat:s of Califorr,Sa.- The cpp:izara mus�fot-lltequip inspections. Comp?e:e drawing on reverse side. Si_r<ed X_. __ Title: ', ,o ; Date: FOR DEPARTf✓ENT USE ONLY r ratio:ion :,ecEp:Ed by Z4 Dale � ® � Area ✓,� Pit or Grv�t 1^ ectipn by Dave Final Ins •i b = Pec,on .y C SA C odi 5Y3-3E t:an:eca 823.710-. ❑ 'Tracy E35-F;° / APP17CL-1 ^E:u:n cit copies to: wn.iio- -,En:at ^eal;h Perm::.rSenvices '.503 E. HE.elton A_ve.. P.O. Box 2X1 3, .S:k., CA 2E.201 DL. �1:.D)r:T r.il:,liiED A-0� F.ECEI'cED EYLATA PEA."7 r:3.