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APPLICATIDN F''3iq PERMIT <br />SAN J41AQuiN ILOCAL HEALTH DISTRICT � ' � <br />1601 E. HAi£LiON AVE., STOCKTM, CA � � PE$i°iT NO. �...-_.�,,,,�•,W,,, <br />telechone (209)°465-6761 f DATE ISSUEDIL-2-:13 <br />'iTRM;T EXPIRES 1 YEAR FROM DATE ISSUED " <br />(Complete in Triplicate) <br />,rn <br />Application is hereby Tide to t Q San JOaquin Local Health District ror a perwit tO construct and/Or install the work herein <br />described. This application is made in Compliance with San Joaq in County Ordinance No, 649 for sewage or No. 1962 for wall/pump <br />and tine Rules n Reg laations of the San Joacuin Loca1lN 8} * trict. <br />Job Address _­41tW Itl '�/,ilAlla vision Name �• _ _. <br />fjHner's hamsriZI lR�odress _..~ 0^ <br />7� <br />3 CJ',•{lGa1Y License No L/�+�! Q Phone i�� 3"���^�_ <br />Contractor's Nam 1.1t -. <br />TYPE OF WELL/PUMP WOKK: NEW WILL WELL REPLACEMENT n DESTRUCT YON � ! <br />PUMP ;3ST4LAT•0ti SYSTEM REPAIR _.l . OTHER 40 <br />DISTANCE TO ?NEAREST: SEPTIC TANK ..SEWEA LINES_ DISFOSAL FLO, PROP. LINE <br />FOtJNIA"10N i AGRICi1LTJRE W£Lt.. _ OTHER WELL PITSISUMiPS <br />tNTENDEO USE TY?£•Ox WELL PinstEM MCA STRllCTION 5i'£C;f CAtI <br />i y industrial ~. r j Open Bottm j Manteca. 9i a. of 'Well Excavation <br />i <br />71Doanestic/?riaate �[ Gravel Pack of Well sing <br />pubic " r.! Other W Delta Type of Lasing <br />lrrigazian Approx. F4 stern Specifications <br />La ._ <br />n Cathodic Protection Dept' & depth of Grout Seal <br />17 Geophysical ' Type of Grout <br />C3Other Surface Seal 164t.alled by <br />Repair work Done ED Type of ;lump E�. ' - H.O. _. <br />well Destruction E] Well Diameter Sealing Material <br />Depth Filler Material <br />State Work Done -- <br />(top 50') <br />(Selow 5D') <br />__ <br />TYPE OF SEPTIC WORK: KfW "NSTALLAT!0N Li WAIRIAr8ITION ("Z (No septic tank Or seepage pit permitted if public sewer is <br />I available wit"in 201) feet.) <br />Installation will serve: Residence _V Cor rcial _ Other _w <br />Number of living units: _ ,_ Number'of bedreor,s L _ Lot size <br />Character of soil to a depth. Of 3' feet: �bii Water table depth <br />SEPT LdJANK.,,..._ - G ... _ xypal`"f9 . Capacity <br />PKG. TREASMENi PLT. Type/Mfg Capacity _ _. _ Method of Disposal <br />SEWAGE SYSTEM Distance to nearest. 'leen _ Foundation --- Property Ling,..._. _ -- <br />DESTRUCTION I <br />L"eACHING LONE Length Of lines J"' Total lengthlsixa • . <br />FILTER B 1� Distance to nearest: i+Nell``i�..-, FOdatianiyl Property Lina <br />ri <br />Distance to nftrMt; WeiI �Foundation <p ty�Lin � <br />S1J,+lPS . <br />DISPOSAL PONDS <br />I hereby certify that I have prCp red this application and that the work wilIibe dons in accoriiaru+r with San Joaquin ccumty <br />ordinances, state laws, and rules. and regulations of,the San Joaquin Local }ioalth District. <br />Home owner or licensed a it's siggnature Certifies the ,following: certify that in the perf6r�nc� of the work for which the; <br />permit is issaed, I shall not c^nploy anypersrsn i» „s3£ Wenner as to becoraz s�rbeCt to wr}rkmani, ctpens�ition Saws of <br />�rsrria." <br />fy that ivr <br />Contractor's hiring or sub -contracting signature cer',ifies the•following: "I certithe perforsranrts of the wdrk �aY ,hicn <br />this permit is issued, I shall employ persons sublecl- to workran's COMW atian laws Of .al' <br />forni " Y7 <br />The appsice t call for ail requir iiispeciions"Lomplete drawin&� reverse Date: <br />Signed Y, �afi!!t` .K - k Title: <br />}� ELLE. ...._.,........... - , <br />'Y : .,........................ ELLE. . k <br />PAiIT" eN'° E ONLY 0 Stk 466-6791 <br />Apgiitation Accepted by __ Area �. <br />_�_. 7 <br />Lodi 359-3621 ' <br />Additional CWM"tS;�.._ _. -_ �, - -.--�► <br />- a� Manteca 823-7104 <br />ti <br />Pit Or Grout Inspection t late _. _ <br />_� _. Al <br />Final Inspection by ___ DateZ_._ tf t Tracy 83u-6395 <br />1W ice,. <br />o - a,�t,,,-n All cania . Environ l Healtn Permi"IS—ica. 1601,". Hazelton Ave„ i.0• Box 7009, Stk., CA 95?Oi <br />' EH 13•-24 REV. 10/92 <br />1D-26 <br />%/-Vgry <br />10/82 600 <br />r <br />