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'� a2 { 41 �3 <br /> f _ APPLICATION FOR PERMIT <br /> 01 <br /> 4;p. <br /> r <br /> AN JOAQUI L AL HEALTH DISTRICT <br /> ,F 1601 E. HAZELTON AVE. STOCK <br /> w TON. CA <br /> ti e Telephone (209) 466-6781. ,v?) ', 3 ..W °gra <br /> 'PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> f& r {Complete in Triplicate} r ,; <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 4—7/-"7 &u _ Z::--__ City _� _ Lot Size&EX 7,Sl� PM <br /> Owner's Nam,<aALj zkALj V Address ���7� _ ------ __ Phone <br /> AL <br /> Contractor Addres ' ^4 !License No,/ Plio <br /> TYPE OF WELL/ <br /> BUMP:.. NEW.WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST. SEPTIC TANK'.'-' SEWER LINES DISPOSAL FLO. PROP. LINE - <br /> F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> LIM <br />' INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public [_] Other n Delta Depth of Grout Seal Type of Grout r <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seai Installed by <br /> Repair Work Done ❑ Type of Pump H.P_ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 _ V <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION (.1 REPAIR/ADDITIONA, DESTRUCTION I 1 (No septic system permitted if public sewer is v <br /> available within 200 feet? t ' <br /> Installation will serve: Residence Carrxttercral Other x <br /> s <br /> Number of Crying units: Number of bedrooms _ <br />, ;.. . Character of soil to adepth of 3 feet: Water labia depth' <br />•��"w "'•�SEPTIC TANK. Type/M}9 �_� L T Capacity &_:e"'C_ No. Compartments <br /> PKG, TREATMENT,.PLT. ❑ a f Method of Disposal <br /> i Distance to nearest: Well Foundation I Property Line l ;' ` <br /> 1 <br /> LEACHING LINE No..tlr Length of renes _ ._ <br /> ... . .. 17 Total length/size <br /> r FILTER BED ❑ Distance to nearest: Well Foundation Prope — Lei---- b } <br /> 6 a <br /> rty Li 4 <br /> SEEPAGE PITSA. Depth Sr Size Number, Cj <br /> SUMPS $ Ll' Distance to nearest: Well Foundation _ Property Line _ <br /> DISPOSAL PONDS u: Cj......_.. ��........_. ..... .� -. <._ > ., _..��� .... - 4 <br /> yl hereby,certify that I have prepared this application and that the work will be done in accordance"'— an Joaqui[i conn ordiiruncea,atat�i;ii, and <br /> `c rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensee agent'signature owd ies tfte following: 'I certify that in the performance of the worts for_which dds.pertrrt is t"not <br /> ernployyany person in such manner as to becwrte subject to workman's compensation laws of California."Contractees hinrp qr suurecertifies the loHpwirrg 1 certify that in the performance of the work for which this permit is issued 1 shalt—ploy Ga[Qan <br /> �' ,tion Maws of Ca6fomir."w <br /> pe p Y peraana subjeet tvvvork[riarrls sa . <br /> Thea rcant�11 fo[all i ed i � <br /> � raga napectkmw Complot rawing on reverse side - <br /> Yt-.. - � tri <br /> �' a '#. ,� ;ate . .'� �e �.-�, •;� <br /> a .., :Signed Tnle:. r Date: <br /> Th <br /> DEPARTMENT.USE ONLY. a s <br /> I six <br /> Application Accepter!by <br /> ;, <br /> Pit or Grout lnapdctionwbY ° <br /> Fi <br /> Date nal Inspecuart by 33 <br /> s <br /> A nt a1` .a1 :ptptes Jq' Err ranmerttat ermttlSenribsa t[il]l E.H+�lton`A JX;Box 2009 S A''`CA 915241 R� <br /> +G}vStk 4886781 ] i 3t�-_3821, ❑Ma teca'^.823 7104 <br /> 3 <br /> ,NF_,t,L�UE gEM#T'riiQ �H�� IRECEIV�IEI'aR� oATI%-_ ,RERM�If:'r'' <br />