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APPLICATION FOR p£RMs'T ;
<br />I
<br />SAN JOAQuih tCcAL i�EALTN DISTRICT
<br />1601 E. 4AZZELION AVE., STQCX701, CA PiRi�lT NO,
<br />Tel eOdnle ( 2491 466-6781 `
<br />DATE ISSi;E6;e7
<br />PE IT PXPIRES 1 YEAR cROM DATE ISSUED
<br />('omTaete, in Tripl iea,te)
<br />Application is hereby made tc the San Joacu4tn Local Health District for a pernit to construct and/or install the ,work herein
<br />described. This application is made in compliance with San 3oaquin iounty Ordinance No. 549 for sewage or No. 1862 for well?pump
<br />and the Rules and Re4ulations of he San Jcaquir. Local Herrin: District, w
<br />,lab AddressU, 2-112, TZ &Jll55 Subdivision Name
<br />Owner's Name , E�M My__.S.�rA.w17VA) Address 50iriaar Phone
<br />Contractor's Name - l.icenw *, • .... tete _
<br />TYPEOF WELLJPU,'OP FORK: NEW WELL.
<br />0 WELL REIP ACEMLNT
<br />L DESTRIXTION L]r
<br />a
<br />,--._— --PUMP,.., 1,N5TALLATION•,
<br />— SYSTEM REPATft....:�s..
<br />rOISTANCE TO NEAREST:
<br />SEPTIC TANK
<br />SEWER LIKES
<br />CISP05AL FLO, PROP, LANE i
<br />s
<br />FOUNDATION
<br />AGRICULTURE WELL
<br />OT4ER WELL PITSISUMPS
<br />INTENDED USE
<br />TYPEL OF WELL
<br />PROBLEM AREA
<br />CONSTRUCTION SPECMWIONS
<br />Industrialopin
<br />Bottom
<br />;ZnteLvZ;
<br />'Dia. of Well Excavation
<br />Domestic/Private
<br />D Gravel Pack
<br />' Tracy
<br />Dia. of well Casino
<br />Publ is
<br />irrigation
<br />�j Other
<br />[_j Del to t
<br />' 4r
<br />Eastern
<br />Type of Casing
<br />tfw."i
<br />Approx..
<br />Depth
<br />[j
<br />" Specrficatior t
<br />Cathodic Protection
<br />: Depth of Grout Seal �
<br />C>Fwphysical
<br />Type of gout
<br />Other
<br />Surface Seal Installed by ,
<br />'Repair Stork gone 0
<br />Type of Pump
<br />A. P.
<br />State Worke t
<br />'Well Destruction C]
<br />Well Oiameter
<br />Staling Material (top 50';
<br />Depth
<br />Filler Mal,r is l _,'BeUw..50'
<br />' TYPE OF SEr'IC WORK: NEW INSTALLATION i) REPAIR/ADDITICN No septic tank or see3age pit permitted if public sewer is
<br />f available within 200 feet.)
<br />installation will serve. Residence Commercial other
<br />Number of living units: Number of bedrooms 11Lot size - t
<br />Character of soiltoga Asa pth of 3,feet: yr Water table depth
<br />SEPTIC TANK Type/Mfg 16=_. _ _ Ca.)acity No. Conpartnients
<br />PKG. TREATMENT PLT. 7 TypelWe .rapacity Method of Disposal
<br />SEWAGE SYSTEM Distan
<br />DESTRUCTION —�-�
<br />LEACHING LIWE fir✓ dn. &
<br />( FILTER BED Distan
<br />to neareit:we17
<br />Length of lines Total length/size -� 9
<br />Ce to nearest: Wel;7,,._a Foundation J Property Line
<br />,I- .w- -.
<br />Foundation Property Line
<br />SEEPAGE PITS Deotn_ Si re bomber
<br />SOWS Distan to nearest:. 'Wel l _ fbundsitt"on» k_ . Property*fine
<br />DISPOSAL PONDS �I�1e�
<br />I hereby certify that I have prepared this application and that t!+e work will berdone in accordance with San Joaquin county
<br />ordinances, state laws, and rules and regulations of the San Joaquir, Local Healtl*iistrict.
<br />Home owner or licensed a ant's signature r.ertifip, the following: "I certify that.in7the per¢ornance of the work for which this.
<br />permit is issued, I shall not eriploy any person in such manner as to become subject to woeoAant coriper"sation laws of Califurniai."
<br />I Contractor's hiring or sub -contracting signature certifies the'tot lowing,�"i–cert5fv'that°n•-ine-perfn+rrance of the work for which
<br />I this permit is issueo, shatrt*,ploy person's";subject to wo'rkman`•sicornpensatipn )a�,stof California."
<br />. The applicant mast c II fo all .recuired nspettions. Complete drawing on reverse side. F
<br />Signed X Title: VC# Bate.
<br />FO EPART 'Et;" • SE ONLY .. . W
<br />CdLipir 7lccepieby�. _ ArtB Stk w�'4f5-678?
<br />._
<br />1,6e, 369-3621
<br />Additional Convents:
<br />t Pit or Grout Inspection by / '': • y 'e Date ?anteca 823-7104
<br />Date W Trary,..
<br />Applicant -Return all copies ,. Enviresentai.Nea h Permit/services 2601 :, M el ton Ave., P.O, Box ?403, Stk., CA 952%2
<br />e
<br />PEE BASE AMOUNT f DUE AAOUN? "'REMITTED 4R£CEiVED 9Y» � ,✓ � DAT PERMIT NO.
<br />11110 _...,
<br />Eli 13-24 REV. 10/82 i0/ 610
<br />id -26
<br />R;
<br />
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