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APPLIC,P,TI0!yi FP.R�111 PERMIT
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<br />SAN J0AQU1,N;10CA1,,HfiALTH DISTRICT
<br />1601 E.-HAZELTON,AVE., STOCKTON, CA
<br />Telephone 1209? 466-6781
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<br />PERMIT EXPIR'E,r.',1"
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<br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herelri!d'.icritied. This application is
<br />--Coun Ordinance'Nor',549�fqrLLq@Wageior-�No-.Lj=-fpr,.Well.-/.ot4 p, �he�:RulesanO� . . . - quin
<br />rnadi6,,in,coinpjiance;with,sery.,Joaduin. -ty-1 m pnd- -Reglabohs- of the Sari;Joe
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<br />Local Health Distract E,�JT�r)'�'j,,;-iirj
<br />City.0tisize
<br />Job Address
<br />0", .........
<br />Owner's Name
<br />i rase No. Phone
<br />.,:Coniractor's Name
<br />NEW WELL L WELL REPLACEMENT I DESTRUCTION 0.
<br />TYPE OF `WELL/PUMP-
<br />1! - - OTHER ❑Ll
<br />Pump -INSTALLATION L1 .'SYSTEM'REPAin ❑
<br />0,
<br />SPOSAL FLD. PROP. LINE:
<br />DISTANCE TO NEAREST: SEPTtC,TANK, StWER LINES DIC
<br />L PITS/SUMPS
<br />OTHER
<br />EL
<br />AGRICULTURE WELL, 0
<br />FOUNDATION
<br />ION SPECIFICATIONS _7
<br />INTENDED USE TYPE OF WELL; PROBLEM AREA
<br />�ottorn Manteca �Dia. of Weil Excavation _Dia. of Well Casingl'
<br />'D Industrial 0 Open E
<br />A- S
<br />1L] Do estic/Private 0 Gravel Pack 11 Tracy Type of Casi pecifications
<br />M Dept Seale -Type of Grout
<br />'Ib Public C1 Other Delta e of. 6 rout
<br />Irrigation 'n
<br />k �&�:OiSuriace. Seal Installed by;
<br />F] Irriga -L.-Approx. Depth El Easter
<br />I State Work Doni
<br />Repair Work Done 0 Type of Pump :H.P.
<br />Seal
<br />ii (top 50')
<br />Well Diameter O�ing ------
<br />Well, Destruction LJ -
<br />I -
<br />Depth Filler. Materialerial (Below
<br />501 i sewer is
<br />:TYPE OF,SEPTIC WORK: LATION 9 REPAIR/ADDITIONJ71 DESTRUCTION ❑0 (Na geptic:systbrii'permitted if public
<br />NEW INSTAL "available within,206 feet.Y
<br />'
<br />Installation will serve- Residence
<br />.-- ,Commercial._ Other
<br />Number of b7drooms
<br />Numbei of living units. —t— .
<br />4 d th
<br />Water table ep
<br />'Character of soil to'a depth of 31eet: . . , k 1% a
<br />4
<br />00 ! mems
<br />SEPTIC TANK' C1 i Type' Mfg. Capacity - No. Compartmen,
<br />Metfiod of Dispospl
<br />�PKG. TREATMENT'PLT. Ll r
<br />Line"
<br />Distance to nearest Weld Co Foundation Property
<br />Total length/size
<br />LEACHING LINE Length of lines z r - 0 . -
<br />a
<br />"Property L1 e
<br />-to ea und tion n
<br />C] Distance: n re9t ell Foundation
<br />'FILTER BED
<br />lsi7l�_ Numbsr 1.
<br />SEEPAGE PITS i Depih
<br />1! L Foundation Property Line
<br />to nearest; Wei
<br />i.._ SUMPS
<br />_DISPOSAL PdNDS�, 10
<br />San Joiiquin county otclinances,istati laws, and
<br />1 hereby certify thai I have prepared this application a na that the ,.work � will be done in accordance with
<br />_:rules and -regulations -of the-S�an--Joaquinl Local -Health-bistrict.-4--
<br />Home owner or licensed,agent's signature certifies. the following: PI certify that in the performance of the work for which this permitis issued,: I shall not
<br />I c6me subject to workman's�comoensiiition laws of California." Contractor's hiring, or: sub -contracting signature I
<br />�
<br />employ any person,in such -manner -as to -be ipensa-
<br />icertifies the following: "I ��Certffy that in the performance of the work for which this permit is issued, I shall employ!p6rsons subject to workman's con
<br />A
<br />-,,,tion;laws!of.-C'alifornia."�l-
<br />!rse side.
<br />Ar uire, stedrawing
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<br />The applicant must,cal coons. Co'C , o
<br />D'le.
<br />Title e
<br />R DEPART U ONLY
<br />ea
<br />'Application Accepted by
<br />t i
<br />by Date .0 by D,
<br />Final Inspect!
<br />Pit dr Grout inspection
<br />+
<br />Additional Comments: 71
<br />-0100 ---369-3621---'- -Manteca, 823-7104- ED 7rarcy - 835-6385
<br />�M StkJ CA 95201
<br />i Applicant - Return all copies to: Environmenial Health Permit/ Services' 1601 E. Hazelton Ave., P.O. Box J1.
<br />L. . ...... FEE A RE6EIVEO By`�
<br />AM
<br />OUNT blit CASH
<br />AM 0(fNfREt�iT-rEb
<br />NFO A,
<br />PiV- 3
<br />-24 011E
<br />;+ EH 13 V. 16/83)
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