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'MWO'. LOCAL NtALTH `0ISTRICT <br /> R .. < .5...x rr•�., s�,.yL c fit <br /> sE 'HAZEiON AVE , STOGK.�TON;CAr � r 4 �� <br /> 41 <br /> 1L4Y5f 466.6 EI�T: R-0�. 4 }y. 7kp $S�•;i» "�Id'� }.f. A �, <br /> f 8- <br /> sy MY *�t <br /> TIa1=RM1T EXPIRES 1•YEAR FFihM'DAT� ISSUED <br /> z. <br /> s r (CorRpletfl ER Triplicate ? <br /> s; ' _'e -: ny;•y -;_, :r a ,�' Vii` 4 ° : -... - ._ <br /> Application is her4bir Y►ada to She San Jaagwn tocak Health Drstnct for a"permrtito construcC and/or matall the work herein described .TMs application is <br /> made in corr►plianpe with San.3oaqum Count`r O t inanee�1a 549 tot sewage ar No ;84'vor10A pumpend tli8,fiules and I;agulatiorts of the San Joaquin <br /> Local Health.District r 44 ' tine x �1 + ; J i� S ur` tl �,� 13 <br /> City t$x PM <br /> t�- c? La r a <br /> Job Address <br /> Address hone <br /> Owners Name , r <br /> License N&--i', 1.:Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: '; NEW WELL = WELL REPLACEMENT❑ DESTRUCTION ❑ <br /> a " SYSTEM REPAIR ❑ �hOTHER ❑ p <br /> a� PUMP INSTALLATION <br /> DISTAN CETO NEAREST: SEPTIC.TANK �as SEWER1INES _ ^ DISPOSAL FLD,I -_ PROP LINE <br /> FOUNDATION AGRICULTURE WELL-.11 <br /> -�OTHER WELL e- PITSISUMPS <br /> INTENDEI,�tJSE TYPE OF"WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS'.`" S <br /> ❑.Industnal'"dE:: _ Dia. of Weif Casin <br /> ❑ Open Bottom ❑ Manteca Dia` of.Wellxcavauon i 9 <br /> of Casrn Specifications: <br /> i �bgmestrc/Private f Gravel Pack,. t © Tracy Type S <br /> # `-1 <br /> f 1 PubLc �l�— Type of Grout <br /> n Other [ ! Delta Depth of Grout Seal tl <br /> t k frrigauon„* . : Approx D th. . l ! Eastern Surface Seal installed by s! <br /> 3 _ State,Work Done <br /> Repair Work Done Type of Pump + t Y_L H.P. :6 <br /> :,Well Destruction„ ❑ Well biometer Sealing Material ltop 501 <br /> ':Depth" °. Filler Material leelow 50'! <br /> TYPEyOF SEPTIC WORK: NEW INSTALLATION 1"] REPAIR/ADDITION l l DESTRUCTION ! I (No septic system permitted if public sewer is <br /> Fa. s} -: -' available within 200 feet.) ' <br /> Installation will serve. ? Residence�! hCommercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a:depth of 3 feet: Water table depth <br /> ".Capacity No.%Compartments p... <br /> Ag- <br /> SEPTIC,TANK ❑ . Type/Mfg i <br /> e PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> 1 <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER:BED• ❑ Distance to nearest: Well Foundation Properly Line _ <br /> SEEPAGE PITS- I l Depth Size Number - s� <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared.this application and.that the work will be done in accordance with San.Joaquin county ordinances state laws, and <br /> rules and regulations of,the San Joaquin.Local.Health Oittrict. :,. <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 y!shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> } certifies the following "I certify that in the performance of the work for which this permit is issued I shall employ persons subject to workman s compensa <br /> a hon taws of California., ,,.. ,:J <br /> _ cry <br /> The applican L ' UIIJQor all required inspections` Complete dr Ing vn ` verse side,, <br /> ,- <br /> 5i ned t Itle <br /> 9 a.;i>k:, y ; w. x`�°'<' °° -� i������ 7• <br /> f.• +�i -r ' n t '"" � R DEPARTMENT"USE ONLY x <br /> Y R��] <br /> } � <br /> Date' Araa <br /> Applicatwn Accepted by r x i ,y a <br /> � + � <br /> Fe. is a., t Date 'Wall, <br /> ".e <br /> ` ' ` Dat Final litapecuon bye 'i <br /> o ti,,zr i�� lit Grout Inspection by s , '^ r x <br /> [] ltk L6dik! 3621; 9nteca g,$23 7104. ;C]Tracy:835 631 ?Y F r 4 � � `s, s c r„ <br /> p� y. ° 4 Ffaz t vet U, Stk CA.962f)1 <br /> £ tR .:all Cgpietp EnwronmentAl Heal ertni �ertriea x6Q F k <br /> {< kFE NF„ s., T:bU� <br />