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<br /> APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZELTON AVE., STOCKTON, CA
<br /> Telephone (209) 466-6781
<br /> r PERMIT EXPIRES 1 YEAR FROM DATE ISSUEf7
<br /> (Complete in Triplicate),
<br /> application is
<br /> q ct,tlon'u hereby made to the San Joaquin Local Haaith Distr::1 for a permit to construct and/or Install the work heroin described This app "
<br /> in compliance with San.;osquin County Ordinance Nn.649 for sewag^nr No.1862 Ir•wall/pump and the Rules and Regulations of the Sen Joaquin
<br /> Racal Health District.'. - `
<br /> ity 1 -- Lut Sire i+�'�� Pw!
<br /> Job Address �1 .7777
<br /> Address t� 02 II[1 Phan
<br /> ' x Orrrters Name '
<br />+qtr` xtrl; ConVac a`" .9/1�Address" V' Llccnse No;T
<br /> � .MgTYPE OF WELL/PUMP: NEW WELL L WELL REPLACEMENT 0 DESTRUCTION Q
<br /> PUMP INSTALLATION © SYSTEM REPAIR C3OTHER 13
<br /> 4
<br /> . �;,"-.-.^h'.r,:*'.'. •.%`t':' DISPOSAL fLD. PROP. LINE
<br /> r ;j ik+ aDISTANCE TO ti-AREST: SEPTIC TANK' SEWER LINES
<br /> AGRICULTURE WELL _�_:OTHER WELL PITS/SUMPS _
<br /> FOUNDATION
<br /> 4 pINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> t ❑{Industrial
<br /> r :d Open Bottom;, ❑ Manteca .Die.of Well Exceyation Dia.of Well Casing
<br /> peclficatbns ;! I :N
<br /> t 1❑DomosticlPrivate` r 'Cl Grevef Pack C3 Tracy Type of Ceeing�� 1;
<br /> -1f v,, •/r I ❑Other - ❑Pelta
<br /> Depth of Grout Seal Type of Grout
<br /> +'h H ,' ❑�Illlt:�f kl I -_
<br /> t,} lrripsS�io+t ;, rn �Jlpprox H.A.
<br /> }Pump Depth ❑ Eastern Surface Seal installed by M+
<br /> State Work Done
<br /> � f'yn R"VWork PoQ Typo,.o ' --
<br /> 'uWaB peswctan �e ''Well Diameter Sealing Meter!al Itap 60'1
<br /> ? •M�'It. r+ a ala'.} ''t ' Depth' filler Material{Below 601.. ,.
<br /> r.t• � •`
<br /> Atirp� � TypB jP SEPTiC WORK: NEW INSTALLATION HEPAIRIADDITION❑-.DESTRUCT!ON U aNa°labperwlthino[00 feet Ig�:rf public
<br /> sewer 4s r 1
<br /> D !! Inatallatron will serve. R encs Commercial_ Other + .
<br /> ,a� iNumber of,xving units:,, Number o!be MGM j
<br /> }�}1 ,:,..Water Ia.ble depth-
<br /> Chsracter of WN to a depth o!3 feel zQ
<br /> Q No.Com rtments
<br /> jSEPTIC:TANK �'"I]:' Type/M'g _ C'Q Capacity_. _ a Pa , 1
<br /> ti I t r Method oI D' Sal
<br /> PKG.STRI ATMENT/PLT.❑ f `'
<br /> OO Foundation' Property Line ;
<br /> Distance to nearest: Well - --- ? L'U
<br /> i N` ,L -ACVINa LINE + c ❑ No."a Lengil.o!lines Total length/size —
<br /> ,' G] .
<br /> Distance to nearest Welt���� Foundation' f ' 'Property Linc �
<br /> ` FILTER BED
<br /> h :�YefP1. �.
<br /> r I f s+ rr Size Number
<br /> SEEPAGE PtT,S .r+ CI D pth i
<br /> Pro Line `
<br /> SUMP*S;r!w;i f. a-, ❑: Distance to nearest Well FoundationPent
<br /> t IrDISPOSAL`PUNDSJ
<br /> t I:hye�oy txi�Y that l'have prepared this application and that the work will be done In accordance with Son Joaquin county ordinances,state larva and
<br /> k , trulp',�nd rspulstiona oflthe Sen Joaquin Local Health District.'
<br /> ' Homs•owner a licensed somt's signature,certifies the following:"I certify that In the perlormante of the work for which this permit is traced,l shall not,,
<br /> •?E empbtl any Person, such manner as.to lieeorr a
<br /> subject to workman's compensation laws ss ed,California."shalploy croons hiring
<br /> to workman s con4petnsa-
<br /> " eaetHi�tfte}oRpwirtg:"I aptly that in ehe performance of the work for which Chit permit is Issued,1 steel)employ pe
<br /> taws_of CdKania.'j _ ._, ,, : ;.
<br /> ,Y t uIred I Ito ns.Compiote drawing on rovede aide I �,
<br /> Date:
<br /> asign
<br /> Title:—,
<br /> 4
<br /> ` FOR DEPARTMENT U$ ONLY (/fes/ y
<br /> Date Aree
<br /> i pppllcetion Accepted by
<br /> Date ,
<br /> r Iby
<br /> Final
<br /> E
<br /> Lrfv .� Pit or Grout lnspection by
<br /> i ,1J" gdditionsl Comments: -
<br /> s` C]Stic 1666781;. Lod) 3l3B21 ❑Manteca 8xi•7t04 Q Trecy,.8366386
<br /> 'Apptleant-Return ell cel,es to: Environrnentai Health Permit/Services 11101 E Hazelton Ave:, P O.iBox 2009,Stk.,CA 86201 - 7
<br /> ret 1 :1 L, TEE . :'•AMOUNT DUE- AMOUNT REMITTED cAsi+ eRECEiVED BY DATE PERMIT'NO
<br /> r " INFO �J,] {'l .
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<br /> (REV,t i sl
<br /> � •.� '_:.. - � ,ti.tiy..,5:a ii f7��i..r- p. a{ sG{7;,. I.
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