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i New, 4PPLICATION FOR fERMiT SAN JO&OUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE , STOCKTU4, CA Telephone (209) 456-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete ;It Triplicate; San Joaquin Local Health one.ct or a Permit to construct and/or install the work herein described.TMap Ties pWAn"m Applkaliun is holebT made to me is t compliance hired with San Joaquin Cnunry Onliwnw No,:rf9 for .,go or No. !E621n,well/pomp and Ire Rule,and Regulatinro of the Sen Josquin ,tape in ion Local Health District. ' PM Et CCityy_rrP/c�l�'L'oi Size — _- Jcb Address l .niV�j✓ A.. ress -- Phone lee, Kartw f-fY--'�-�- ftu/ x�- .5 ? 1 �F:fI�rJ�—i / �,tr910 PhOre Comrac _Adores; �i<ense Ne I TYFF OFF WELUPUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C ' r ----- PUMP INSTALLATION ❑ SYSTEM REPAIR L3JTHER-❑ - __-'�•PROP. LINE --_- DISTANCE TO NEAREST: SEPTIC TANK ._ SEWER LINES DISPOSAL FLU. -- j FOUNDATION AGRICULTURE WELL ._ OTHER WELL. PITS/SUMPS l r, 1lITENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of wog Casing ❑Inlustrial ❑Cpan Bottom C7 Manteca D.J.of Well Excavation_ Specifications; C Domestic/1"Imate ❑ Gravel Pack ❑Tracv Type of Casing i l oublic ❑Other fl Ca•a Depth of Grout Seal __ — Type of Grout c+' 1 r I Infa tion _Appso.•. Depth I I Eastern Surface Seal Installed by O i ' RePsi;Work Done C] Type Type of ihlmp State Work Done 1 Well DestrucifbU ❑ Well Diameter Sealing Malarial(top 511') Filter '1 _ Material(Below 50 e^ Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I hEPAIRIADDIT10N DESTRUCTION 1 i (Nosepticsystem tiAn 200 feet l�d public sewer is i Imul'ation will serve: Residence__ Commercial A Other Numt<z of filing units:4- Number o7 bedrooms : • ... S _Water table depth Character of cdl to a depth of 3 1»c No.Comparbnenn z' SE?r.0 TANK CI Type/Mfg —_ Capati[y_�- / Method of D'oposet I t ' PKG. TREATMENT PLT.❑ s Di„anco ra nearest: Well Z20 Foundation — Property Line 3=, Total to gth/size- . LEa.CHIlIG UNE Cl Na. F Length of limas _ 1 I '7�_� Foundation�-Pfbpntp;Line - FILTER E:eD ❑ Distance to nearest: Well Y' 1 SEEPAGE PITS 1 1 Depth J __Bice Number_ SUMPS Foundation t Prgxrry,line Cl Distance to nearer We!I DISPOSAL PONOS ❑ I hereby certify that I have prepared This application and that the wo-k will be done in accorc'ance with Ban Joaquin county ordinances,state 4vrs,and r rules and regulations of the San Joaquin Local Health Wastes_ -- -”- - } Hon10 awwr a Gconaeu agent's signature certifies the loeowing: "I certify that in the pedormance of the work for which this permit is issued.1 shallow! f i ogmtwe employ any person in such manner as to:racoma sublet to workman's compensatkn lava of Cnli/orale." p!oV ptor'a h;ti or o waskmsn'azb�centrarcds gattle eo' 1 certifies do following:"1 comity that in the pedormznce of the work for which this permit is issued,I xM•!I amP!oy Perigrm, lac r tion Iowa of Califamm" The applirnnr must-Atl for all re aired ids lions.Complete drawing on reverse side. .. . TAla: �!!.�- - Dare: , I 9 F Dfrp EPAHTMEM1T USE ONLY _ `�Y�. ,y Date a` _ Am .� ApplketoAcceptedn Accepted by �-'c-'— Pk or Grout Inspection by Date_--- Final buoemion by _ Date I — _ ! At dd tonal COm"Nol: _ ❑Stk 466-Ml -. O Lodi 369-Ml-. ❑Montece 873-710 - ❑Tracy 835 -- t I Health Permit!Sevieos 1601 E. Haze-zn Ave., P.O. ?ox 200, Sik.,CA WMA Applicant- Return all copies to:Environments 3 iEE x RECEIVED RY TE0ATn1,,,EPE;MrrII0..EAMnUNT Ut12 AMOUNTREMIMO ?n t1 I ..EH 1121 04W.11 /'D. o,� 70 d. tN 14]a R