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APPLICATION,FOR;PERMIT , �
<br /> SAN JOAQUIN;LQCAL,HEALTH DISTRICT �E
<br /> 1601 E.•HAZELTON-AVE., STOCK ON, CA 4
<br /> Telephone (209) 466 6781
<br /> PERMIT EXPIREiY 7 t :.i}t 't'Y':d91 t � 9 �:� '•^� 11s �a�`�' !�? �'25 +I,� !L} a r-r•.
<br /> S 1 YEARrFR�M D�►T kSSIJD w;iip , +; 7 t irllt ;o on";I,,t() .
<br /> mplete.iniTfiplicatelYL,)�i?il,;3r- .,: ,ij,-,ril.: "3{},,jslr); ,-iiri,:tiienel I3 ,u
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her4AJ186i6r&&This application is
<br /> madCtn•cotnpfiance with San;:loaquin;County,Ordinance.No.^549;fvr;sewageror_,No•,1862,for,we111pufnp.grld the;Rules;and Reegulat-ions�o#the SaTJoaquin
<br /> Local Health District a 3_, 3 ;5y !Elr, <* t r 17 zsr i'Vt a rt? lrlt z! rr iJrf L� )1C1
<br /> 'C i;r riiEitri���t} !.. } >�l c s: Ff. I3" (r xF t� g S$
<br /> t: .J rj !'l
<br /> Jab Address of Size, U „J.�,/CK
<br /> r,
<br /> Owner's Name - Address
<br /> Phone
<br /> __
<br /> Contractors- --_ _. -.._. _-,-._ �._ _ ..-., _. r _ ,•--_-�-_
<br /> _ ' Name - �4. ,License No.,
<br /> Phone /
<br /> 'TYPE OF;WELLIPUMP:i NEW WELL ❑ WELL REPLACEMENT L] DESTRUCTION ❑'
<br /> PUMP INSTALLATION ❑ - -,- ` SYSTEM'REPAIR CJ OTHER Eli'
<br /> 1
<br /> DISTANCE TO NEAREST.,SEPTIC TANK_ I __SEWER LINES ,DISPOSAL WELL 4 POOP. UNE
<br /> i '
<br /> FOUNDATION AGRICULTURE WELL 0 PITS/SUMPS r S
<br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS 01
<br /> -;❑ Iridustnal- .. ❑'Open-Bottom : ----❑ Manteca -Dia.=of Well Excavation -,Dia..of Well Casing;
<br /> l i :S ecifications
<br /> 1:1 Dis/Private, ❑ Gravel Pack 0 Tracy Type of Casing-, ri p ._
<br /> omest P _ ..
<br /> hof Grout Seal i f- Type of Grout
<br /> p . .
<br /> ❑ Iribatian- ->• ❑ _Approx; Depth. -,❑Eastern Surface-Seal Installed-by.
<br /> p g
<br /> -:
<br /> Re air Work Done El Type of'Pump H.P.- State Work-Done.41
<br /> 4
<br /> Well Destruction ❑ Well Diameter Sealing Material (top 50')
<br /> S
<br /> Depth. Filler Material (Below 50'M
<br /> J P f a o septic'system permitted if public sewer is
<br /> JYPE OF,SEPTIC WORK NEW INSTALLATION ❑ REPAIRIADDITION'❑ DESTRUCTION l vailable within!200 feet.)
<br /> : ' - '
<br /> I s b i
<br /> Commercial_ Other
<br /> Installation+mil serve: Residence_ _- . + -} -
<br /> Number of living units: Number of bedrooms
<br /> _ ., _ 1
<br /> }
<br /> -Character
<br /> soil to a depth:of 3 feet: Water table depth '•
<br /> Capacity- 'No. Compartments
<br /> SEPTIC TANK: . '. _. ❑ T_vpe/Mfg'._. . - - _
<br /> ;PKG TREATMENT,PLT ❑ Method
<br /> iDistence to nearest:` (Well Foundation- Property Line of Disposal
<br /> LEACHING LINE ❑ No & Length of lines Total length/s i
<br /> IZB
<br /> n o {
<br /> FILTER-BED'_.., - 1_❑ 'Dlstarice'to nearest, Well' P
<br /> . t
<br /> Fou dat aperty�L
<br /> ' ' i...n
<br /> ;Size � Number
<br /> SEEPAGE PITS !❑ +Depth• -
<br /> - (SUMPS © (Distance to nearest Weld "" Foundation _¥ - P- Property Line i'a l
<br /> �. 7� E i
<br /> F y
<br /> DISPOSAL PONDS ❑"! ' !."
<br /> rulesand I hereby $e lulatiorrsatT lt>f the San Dago(Locah+aealth pistrctn� E 1- and i
<br /> p pp (work will be done m accordance with San Joaquin county ordinances, state laws
<br /> i g
<br /> i
<br /> Home owner or licensed agent's signature certifies,the following: :"( certify that iii the performance of the work for which this permit Is Issued I shall not
<br /> --_i employ ary person-in such manner'.as-to become subject-to Workman's;compensation-laws of California:"Contractors hiring or•sub i:ontracting signature i
<br /> "certifies the following: "I certify that rn the perform8nee of the work for which thisipermlt Is issued! I shall`erttploy�persons suhlscf to workman's compensa=
<br /> - tion.laws'of California:" .i..._ _ r. r ai i - •.-; - i (I
<br /> W i
<br /> (The applicant roust all for all r fired inspect( ns. Complete drawinglon reverse side I { I
<br /> Signed
<br /> Title
<br /> _ +
<br /> i I Dat
<br /> 4 FOR DEPART M T USE ONLY ! ;
<br /> _
<br /> Application Accepted by 1. Date
<br /> Arta '
<br /> J, I
<br /> Pit or Grout Inspec#ion by € Date I Final Inspection by m Date Z
<br /> _ i - U ! " q 1._. -
<br /> w - M,
<br /> ditional Comments
<br /> f - Stk -,j6&6-78j.-7i 3621 ❑ Manteca 823 7104 [3 rTracy 83x6385 P { _ I !
<br /> - O Lod
<br /> Ap nt- Return all copies to Environmental Health Permit/Services 1601E Hazelton Ave R.O.-Box 2009 i=Stk CA 95201 1 i
<br /> ... _.. _ i
<br /> ..,_ 1-_CLC .__.a..._ �. ._., ._.-_..+_-_ - _ _-_•: -i_. _
<br /> �I Ed ."' t'-AMOUNTAtMITTEONFO! !AMOUNTDUE + 9' ISEN 13-24 01M 10/MEH 4-21I t. p�� 3 I I [Sh _,��,_-,_�_._�
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