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<br /> ArrPLICATION,FOR PERMIT
<br /> r F SAN JOAQUIN LOCAL HEALTH DISTRICT A. ► '€ ` �.
<br /> }€; , 1fi01 E. HAZE:.i ON AVE., STOCKTO�!', CA # 4
<br /> Telephone (2091 466'6781 t '
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISS[JEDr�
<br /> * (Complete in Triplicate! J I' '
<br /> ' s �, W Application is hereby made to the San Joaquin Local Health District for a permit to coratruct end/or Iristailthe
<br /> twork heroin deeetrbed This epplfeation is
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<br /> made in comp5ance with San Joaquin County Ordinance No.549 fo,sewage or No.1851 for werllpump and the Ruler.and Ref.-ulatldns of the Sen-Josquin
<br /> y ►4 Local Health District.
<br /> t r ,�r�7-[J t Size, Q1,V`'
<br /> Job Address u1 Crh �d�'�`r"`�bgy �'�,?tf6kry1
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<br /> �.� Address f ' + 76 : ?horse n ufiT
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<br /> i. � .5 }��. -�i:x ' - "F-.' ;M '✓ i^. NO. .i` " ',. Yr--,4'�. Phorfal. .0 rK
<br /> �� s •,ConlreCtors Name
<br /> � r Y '.TYPE GF WELL/PUMP: NEW WELL C WELL REPLACEMENT C +DESTRUCTION.❑ k !
<br /> t 1a Yks .Y �`�"PUMPINSTALLATION:❑ �hSYSTEM REPAIR Ci { r OTHER'S" f 4�
<br /> t, ",,,;DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL F 13-,A PROP, LINE
<br /> t• ., - FOUNDATION AGAICULTVRE WELL _—'OTHER WELL` - PITS/SUMPS r�•a
<br /> INTENDED iJSE�;-�, TYPE OF WELL'
<br /> PROBLEM AREA 7'CONSTRUCTION SPEC IFI:'ATIONS:
<br /> f T w » fF.
<br /> ;} i7 industrial=: Open Bottom . Q Manteca Dia. of Well Excavation'' Y'�r Dia of Well Caaf4 . y;
<br /> a r.. r, b'"�f''t: ;i;w- ,�$ 1fit81cOR8 �t ' >• `
<br /> - rev.!Pack` G Tracy T of Ca$In pec_
<br /> ' C DvmeatrclPrrvate � :7 G cY Ype g
<br /> - Q Public, = L7 Othertq. u Delta Depth of Grout Seal Type of G ovt� l '
<br /> t Q irrigaiion Approx. Depth C Eastern Surface Seaf installed bY_
<br /> 'r7.
<br /> 's4 Repair York Dane C Type of Pump H.P. State Work Done
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<br /> Well,Destruction Q:. Well Diameter sealing Material(top 50'I
<br /> Depth Filler Materia;(Below 50'1 r r
<br /> tq STYPE OF SEPTICWORK:,:NEW,INSTALLATION❑ REPAIR/ADDITION G DESTRUCTION IJ,(No septic system permitted if public sewer,ls
<br /> t+r ,
<br /> °. . ' kak ,. r rt available wrthin 206 feet),V s y�
<br /> 'f i yy` 4F , 3 a5 f�: I -. w I 7 3'rr�';f 7r �y t
<br /> *: w• +'Installation wilt serve: Residence Commercial_f�,Other c) tl .yx �r cs e`1
<br /> " Number of Erving units: ' Number of ooms
<br /> Character of soil to a depth of 3 feet;: Water table depth M `• S,
<br /> 7 ..,w �3 -A--
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<br /> A
<br /> �A SEPTIC.TANK � C] Type/i<+1fg�_�rj �Capacity _ No.'Compartmartts'.
<br /> ,PKC,TREATMENT PLT " Disposal [ " \`
<br /> r 14 }Method of
<br /> Distance to nearest, Well 'f v_ foundations Property-Erne ' 'x - 4 yO
<br /> .pke,-
<br /> Vit¢, - Yfs LEACHING LINE i7 No. &Length of lines lengthtsize`` r
<br /> :FILTER BED a C Distance to nearest: Wel; ()-a rr'Foundation 1:' Property Line
<br /> SEEPAGE PITS'- O' Depth Size___ Mumber rr�,
<br /> SUMPS ` r Distance o nearest: Well t' Foundation 's Property Line~r`tY w
<br /> DISPOSAL PONDS - ! jl9UAR Jif - df
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<br /> I hereby certify that I have prepared this application and that the work vvill be done in accordance with San Joaquin county ordinarces,State laws�ertd - a
<br /> rules and regulations of the San Joaquin Local Health District,
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<br /> Horne owner,or licensed agent's s;gsiature certifies the fcllowing:"I certify that in the performance of the work for which this permit is iss. lasheh note x
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<br /> �!4 employ any person.in such manner as to become subject to workman's compensation laws of California."Contractors hiring or subcontracting signature
<br /> t y certifies the following:"I certify'that,in the performance of the work for which this permit is issued.!shall employ persons subject to workman s compertsa
<br /> ,* 3 :tion lawe of Cafrfornie,.. > �L
<br /> r91�s ;uThe applicant m Jt it I requires/rrj pections. Compfe drawing on reverse side. 4 �e
<br /> irk. ry. /f' 1.1.. } r �A�/�` � ' rC4TrYi ,i Date. '�s I ��erfiYs*r+{ r?
<br /> Signed ati Title: • �Sw
<br /> u Mr� FOR DEVARTM'ENT USE ONLY a b f' N
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<br /> Application Accepted by - 'Dratte,
<br /> Yrs+ -� a•� 1- 'A., . -',F ..- V i- 3' fY ,.t. 41L yq .+>R � .
<br /> { ry Pit or Grout Inspection by x Date r`l _Final Inspection by ,h "" ' 0 7J_/`Gr/a[j_rt• *.' f
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<br /> �� Additio_na1 Comments .i• ` ., - - ".' �� i:.'t �. �`�'W.�`f#. a•.�`r �,•� ��� a.
<br /> Sik 46&6781 C L[di 369.3621 ❑Manteca 823.7104 r y, L]Tracy 83Sfi385 qji a a .s•'r 'r "
<br /> ^` Applicant-'Return all copies to: Environmental Hesfth Permit/Service s 1601 E:-Hazelton Ave."P.0. gox 2409 Stk':'CA 95201 r .„'v t ,I
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<br /> a i rn FEE --�- CK x, r h�.-'a 57AT '+
<br /> u a -” as-�'� INFO. AMOUNT DUE or" 'APAOUNT REMITTED � L CASH �a 'RECEfVED 8Y A t,DATE- :.PERMR ND.,
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<br /> ` FH 132 IF EV.SOr831 L-1 t.c + 'jai J:/1/ xr { 21.!_t.�S`73F -
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