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APPLICATION,FOR PERMIT
<br /> k2 "V,. Yis',.;c
<br /> SAN JOAQUIN:,LOCAL HEALTH DISTRICT
<br /> 1601 E.,HAZELiON:AVE., STO,CKTON, CA
<br /> �Tel�phone 1209)466-6781
<br /> 'Y3 '. }e' y. �e�•"3?'I U�U,rs�� 10 e"-�`,a'"�"{�•� �;°.+ r-+1'�ir='fi .�
<br /> PERMIT EXPfRES 7 Y,I FROM DATE.ISSUED
<br /> �xa(CQmpl%Tq in Trlplicate)N,.t
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein'descrit ed; This application`is
<br /> °made_in.coinpliance Withr$an'Joaquin.-County,Ordinance No:,549.for,_sevirage.or,No:;1862 for.well/pu"mp,and the Rules�nd;Regulations of the�San,Jobquin
<br /> Local Health District . "
<br /> il(7t3 i il3rl i,' f ? °3u?1:0e -:�kflaFoq =14djo yPz 1 1" :1 r>� )3 e• 3x,%20�-
<br /> 4 _..V.l(, .1 �- 4( Vr' .r+Y t'T �� r,rll flo s'`��3 7 Y ' 3 �,+ , y i --Al
<br /> Job Address Cc! � E �^ t;`s �� c l � O D `
<br /> -._',Lat:Size �D[9JX�c°ll.J, .PM ..
<br /> �.-mss..."................ .� .......+.—. .p..�. ..._.._
<br /> ti
<br /> Owners Name Address "�" : ,.'� __._w - """Phone- - e: '
<br /> O7}traCtOr 5 Name i_.". }' "F _License No x: # .`
<br /> Y Phone1
<br /> FTYPf OF-WELL/P M 1 NEW WELL ❑ WELL,R EPLACEM ENT ❑ DESTRUCTION ❑,—PUMP INSTALLATION-RfP._ i - -SYSTEM-REPAIR ❑ OTHER ❑
<br /> tDISTANCE TO N_ EA_REST: SEPTIC TANK I SEWER LINES I DISPOSAL FLD. PROP, LINE
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS
<br /> t INTENDED,USE+ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> -- ❑ Industrial
<br /> 3'4.9 ❑ Open.Bottom :.-•--"❑ Manteca ..!Dia.'of.Well-Excavation :Dia.'of..Well Casing Q
<br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications
<br /> ❑ Public' �- i ❑ Other € ❑ Delta De th of Grout Seal
<br /> r p Type of Grout
<br /> ❑ Irrigation - Y gpprox. Depth ❑ Eastern - Surface Seal Installed by. J
<br /> Repair Wark Done ❑ Type of Pump 1 s ;H.P.- Sic a Work Done
<br /> Well:Destruction - �❑tW 11 Diameter ,:Sealing Material (top 50') -
<br /> q
<br /> ".-, Depth-.. Filler Material (Below 501 `
<br /> ,TYPE OF`SEPTIC WORK: NEW INSTALLATION X ;REPAIR/ADDITION ❑ DESTRUCTION ID (No septic.system permitted if public sewer is
<br /> " - -" ""-''r " T available within:200 feet.)
<br /> It
<br /> +;}-lnstallation will serve: Residence_f Commercial's Other
<br /> Number of living units; Number of"bedrooms
<br /> Character of.soil to a depthr of 3:feet:" }- - - Water table depth Q
<br /> SEPTIC TANK ❑ Type/Mfg i �'�! Ca No. Compartments' '2r
<br /> .- pacify �� 'F
<br /> yP Gr. TREATMENT PLT. ❑ i ! # ;Method of Disposal
<br /> T ' �" a '°" Distance to'nearest' Well " ' Foundation Property Line "
<br /> ' t „
<br /> LEACHING LINE { 1❑ 1 No. & Length of lines S O. Total length/size d
<br /> "rFILTER-BED" .y ❑ ,Distance'to nearest:' Well, "Found' ionPro e
<br /> P,rtY"Line
<br /> SEEPAGE PITS
<br /> ❑ 'Depth t Size i
<br /> , � Number • '
<br /> ?SUMPS ? i "` ❑--fEDistance to nearest ,Well-` - --Foundation, Property Line
<br /> F (DISPOSAL PONDS , ❑ 3 [ > i
<br /> I hereby certify that I haeme prepared this application and that the work,will-be done in accordance with San Joaquin county ordinances, state laws, and
<br /> rules_and`regulations.of4he:San Joaquin Local-Health District:
<br /> . _._
<br /> Home owner or licensed•,agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not
<br /> employ any person!n-such.manner.as-to.become�subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature
<br /> certifies the following: "ficertify that in Z performance of the work for which this+permit is issued,I shall employ persons subject to workman's compensa-
<br /> - fi tion laws of California."F. , ° -� _ r•. .,..
<br /> The"applicant must call for all required inspections. Complete drawing on reverse side.`
<br /> 8 ,r.
<br /> �Signed 1 f Title Dater
<br /> �
<br /> f l R DEPARTMENT USE ONLY
<br /> Application Accepted by _ /�� f
<br /> ` Date Area
<br /> }Pit or Grout Inspection by R t Date Final Inspection by Date �I
<br /> —4-
<br /> I Additional Comments:
<br /> 46 -6781- —❑ anteca .823-7104 ❑ Tracy❑ Stk �
<br /> Applicant- Return fall 835 fi385 ► -r m 1
<br /> copses to: Environmental Health Permit/Services 1601 E. Hazelton Abe., P.O. Box 2009,iStk.; CA 95201
<br /> �--- r r INFO tAMOUNT DUE f�' `—AMOUNT REMITTED— "CK ;RECEIVED BY q" L. T DATE �" PERMIT`NO.
<br /> +' EH 13 24EV.10183) I w. CASH 4-. . �}
<br /> — EH,� .l_ mew. . 1 s -75S'
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