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i' r .w•c ��- _ 1 .. APPLICATION F11n1PE•,bl LQ L..Z �, tt ..� ~ "4i�e:j s'# `.� i,•
<br /> S.k JDAQIi: LOCAL HEALTtS_3i .y►'r 14i te�?�ti-�ti::<r
<br /> 1601 E. HAZEL 30ri AVE. �'TOCKTGN cl. vtlilY E.C.t,`tRMI
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<br /> Telephone (209)'466-6781"1': M1T N0. 8.iJ\e
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<br /> PEPR'T EXPIREES-1 YEAR FROM DATE IS{s172S,. �f�• QUi�^�O�i�i,
<br /> {Co plete in Triplicate)'
<br /> M - -'_ear - t..,Y�':. r•.• f�` ..
<br /> Appluation ds-hereby made to the San Joaquin'Locai Health District for a permityt0'construtt'and%dr,instal ,thb woik'herein �cK�g .:��.r
<br /> .} „de;tribed•a This appi.itation is made in compliance with San Joaquin County Ordinance No :549 for sewage or.No 1862:forwel•1%pump� `a"
<br /> ? y ' 'fru And the RuleS`'and Regulai ons of the_San .]oaquin.Lotal:Healthr_District.;. ��,,,�+ 6
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<br /> Job,Ai
<br /> '7� IIA, ,Subdivision'Name
<br /> .,filo �, - r, Owner s:Name Address; S . y : Phone: ';'
<br /> Ccintrattor!s NaiPe License No.:�9OTYPE OF;
<br /> _ _ ..moi�'.�•.
<br /> ELL REPLA{rEMENT © DESiRUC71ON❑
<br /> DlSTANCE74LNEARESWORK PT C TANK WELL 0 WYSTEMtREPAIR OTHER
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<br /> # g z r y .PUMP INSTALLATION S K
<br /> ` 4 SE I SEWER LINES;,
<br /> PIS°OSAL FLO PROP;LINE
<br /> r--
<br /> ? FOUNDATION AGFICULTURE fWELL' i' OTHER WELL'- PITS/SUMPS ti U1'
<br /> 1r3 a INTENDED USE
<br /> ,Qr�t3S TY?E GF WELL
<br /> PROBLEM AREA CONSTRUCTION SPECIFTCATIONS: 7 l v
<br /> Industrial,s U Open,Bottom []Manteca-
<br /> Dia'.ofe1'1 Excavation r S �
<br /> ��`i r y Domestic/Pr vale 1 Gravel Pack r TracyDia. of Wei] Lasin "
<br /> G 6 L�Pubit2.. "❑Othfr. :.]Delta
<br /> y" .. Type of Casing "
<br /> rrigatiun APGr`ox ❑Eastern l tT!
<br /> s rt Q,Cathodie Protection death Pecaticatians y"�
<br /> 1.` Depth of•Grout'Seal
<br /> i�Geophysicai
<br /> ti � s Type of Grout
<br /> k ❑Other
<br /> �'' L Surface Seal:Installed by, .0.
<br /> �L-xyf ry F Repair Work:ibne 'type 0f Pump: �H P .'s State Work-Dp e'
<br /> Well Destruction ❑ Well Diameter Sealing Material {top 50')
<br /> Depth . Filler Material (Below 50')V.
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<br /> a1 ,'t1 7 4 TYPE OF SEPTIC CORK_NEW INSTALLATION Lig REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is.=� a1
<br /> _.•-. avatla6le within:200-feet:)',
<br /> lost llation wit! serve: Residence Commercial Other
<br /> Number of loving units m. Number of bedrooms Lot size ;
<br /> r Character of soil to S.depth of 3 feet: ' Water table depth -
<br /> �+ '
<br /> SEPTIC TANK, �j, `Type/Mfg _ Capacity No.-Compartments,
<br /> r PKG. TREATMENT PLT. ❑ , Type/Mfg [opacity Method of Disposal'
<br /> SEWAGE SYSTEM. Distancetonearest: Well, _Foundatioh' ?Property Line
<br /> - DESTRUCTION ❑ C•3rr r
<br /> ,. .a
<br /> t LM'.1iING-LINE:_ J No. b Length of lines Total Tength/size ( L. "`ut Y,'
<br /> � FILSER BED ❑ Distance to nearest: Well Foundation Property Line
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<br /> SEE]-:,7E PITS !J Depth Size Numher r tti'
<br /> L! Oistance to nearest: Well Foundation Property Line
<br /> of D17P5SAL_PONDS �{
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<br /> I hereby certify that I have prepare( . !s application and that the work will bC done fn accordance with San Joaquin County:' !
<br /> ordinances, state laws, and rules and latio"S of the San Joaquin Local Health District. r i
<br /> Home owner or licensed agent's signatur, .ertifies the following; "i certify that in the performance of the work for which th15
<br /> permit is issued. I shall not en o an• California.
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<br /> Pl Y ! verse• in Such manner as to become subject to wprkrynt,compensation laws of California
<br /> Contractor's hiring or sub-contracting signature certifies the fnllow'.no: "I certify that in the perfornmance of the work for-which
<br /> i this permit is issued. I shall e�:ploy FfrsonS s:bjLct to wnrk•-an's co-.pensation laws of California."
<br /> �a The appli n Hast call far ler fired inspections. CoRpletv draw' an reverse side.
<br /> [ Signed X >~ Title: �ri.��o date:
<br /> Application Accepted by � [, �_ r�" 6 6 _ ❑ ,tk 466.6781
<br /> Additional Ce y^?nts: Lodi 369-3621
<br /> r'tt-Or Grout Ins ' ��--� _ ------_ -_ �
<br /> p ct,rn by _ ELte `arteca 823-7104
<br /> final- Inspection Ly _? _��� --— _ i'•.'� �-Cz � C1 Tracy 835-63[15 .
<br /> C"A
<br /> App) cam, - Return alt o[+� to: _nv:f,,^ •eta "de•.nres.:r•;; _. �,aze on Ave., F.O. Say 2009. Stk.; LA 95201
<br /> F.E i BASE
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