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c - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA - <br /> Telephone (209) 466-6781 <br /> PERM_ IT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> -- Application is hereby nwdv to the San Joaquin Laval Health District tar a pef,ba to cdsseuct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.5491w sewage w No.1662 1.,wel/pump ani)the Rules aiw1 R.O tatiorn o/the San Joaquin <br /> Loo H9al[h Da1.c(. UV ks <br /> Job Address 2Q695 LIBERTY RP _ City CT.FNF.NTS Lot Site <br /> JJ —PM <br /> - Owner's Nam< .,LF"R7_S.r4RST Address ZDb9li TTAFRTY Rn. MEHENTS Phone - <br /> 175 <br /> Ceauaatar'L WAYNE BECK .address 8102 KZLLZY DR STF, ? License No. 489784 phone <br /> TYPE OF WELL/?UMP: NEW WELL L WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> - - PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANC NEAREST: SEPTIC TANK 90, SEWER LINES DISPOSAL FLD. PROP. LINE <br /> - FOUNDATION �L.Q— AGRICULTUBEWL OTHER WELL PITS/SUMPS _ <br /> . . INTENDED USE PE OF WELL PRORL EA CONSTRUCTION SPECIFICATIONS <br /> ❑udustriW ❑ tlom anlecd Dia.of Wel Eacavatior:.__— Da.of WallCa9(g <br /> XDonsestlo/Pdvam ❑Gravel P 7 Tracy Type of Casing— SPacilications <br /> (-)P1mGe no 57,fO) Nta Depth of Grout Seal Type of Grout <br /> 1 1 Initiation - f] 1 1 Easter Surface Suul Inswtlod by -- - <br /> "RnPak Wah U Type of Pump _ N.P._ State Work Oona_ <br /> '-Wel Dez wan ❑ Well oianngter Sealing Mabuial It '1 <br /> Depth File(Matefial(Below 50'1 <br /> yPE OF SEPTIC WORK: NEW WSTALWTI REPAIR/ADDITION 1A DESTRUCTION t 1 (No surim system pefnvuW i/poWic sewer is <br /> iT available within 200 laet.) <br /> InstalLtion will salve: Residence_4 Cont 'C4.11�+7 Other <br /> Nunber of Going.nils:-4— Numiter If ireJdQr�ao[tI <br /> Clwactw of soil to a depth of 3 feel:�ik `i—k' (� ����/ Water table depth <br /> SEPTIC TANK ❑ Typt�Alg ��.t?6 � r - Capacity-Ij No.Compartments 2 <br /> PKG. TREATMENT PLT.❑ - / l Method of Disposal <br /> Distance to nearest: Wel 10 Foundation Property Late Soo,Y' <br /> LEACHING LINE {wl No.8 Length of lines L1a✓�� Tsttal krtgtlt/site 7 Y �G <br /> FILTER BED U Distance to nearest Wel./Ye Foundation _ Propeny Line \ <br /> —. <br /> SEEPAGE PITS Is✓l)aPth � Site AA --/' Number <br /> SUMPS 1.1 OL-tance 10 neared: Well.EIEC_ Faundahon JO� PropMv Line <br /> DISPOSAL PONDS Il <br /> 1 hereby cenify that 1 have P(epafed this apWrcalbn and that the work win be done in accordance with San Joaquin county ordwncessure laws, and <br /> rules and regulutiom of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signatum canities the following:"1 certify that in(be pedobmarco of the work for which the pamtit is issued.I shall riot <br /> employ any parson in such manna,as to beconw subject to workman's compensalion laws o/California:'Conuactols hiring of sub vteactmq signature <br /> candies the following:'T certify that in the performance.1 the work for which this permit 4 issued.1 shall employ person subject 10 wgrknun's cumpenM <br /> if..laws of Caldorna." <br /> TM applicantu�t oak far/OM1,sglc <br /> !y / /� n1. Cmdata drwing <br /> Signed Title: Das.: J <br /> 7� <br /> FOR DEPARTMENT USE ONLY /1 ��� yI QI�1 <br /> Appli-anon Accepted by - r Data_�!L1L_ Area CA <br /> A � Z, f4 -1-001 <br /> Prt or G,o.t Inspection by f /L� c -�Date JJ,�/jy��iFkcal Inspection by /'If <br /> ��`/ Date <br /> Addelfonal Conaffenns: / ��L-L • ��el—L+f'"') <br /> D Sok 466.6781 Cl Lodi 369-3621 U Manteca P.23-7107 D Tracy 875.6985 <br /> APpt,.n, -Rewrn all copies to: Emvinortmenlal Hee1N Petn nI Semicus 1601 E.Hazelton Ave..P O.Bin 2009. Stk.. CA 95201 <br /> MFG AMOUNT We—j—wMIWNT*fi[.ITEOcE H RECENEO BY DATE PE0.Wi NO,i (� <br />