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<br /> APPLICATIO', F04 RBMIT 5
<br /> fi m +' x' S•'ti JOAQ; i i LOCAL ai ALPS WRiCT
<br /> 1541 E. 4AcELTON AVE., STOCKTOh, CA PERM?f 40 i
<br /> { " Telephone (209) 466-5781
<br /> �. �. DATE iS#ED 6< ��
<br /> I rfLLtttFyyy, G� PERMIT EXPIRES I YEAR FRAM DATE ISSUED
<br /> AFi72z i.omplete in rr1o11catel ,h^
<br /> Application. ts=,herebyabde to:the S Jo� fn locaT'Health Nstrict,fora permit to can,tryGt.and/
<br /> i'n`stall the wr�r�
<br /> s, described, +:This:application is made,In compliance with San Joaquin Couirty Ordinance No. $49 for sewage o> Noi -1862 ar wE1lYpumpr f� ,
<br /> i'. Ps ,lr {and the,Aules'+ Mations of,:tie San`Joa in total Health OisCrict. ;tiL 1 F. 3 rl s r
<br /> Job Add_resS IDA Name _ = } �•Jr t4
<br /> t c. .. `t
<br /> i Subdiv,i.
<br /> Owner's Name. Address $}hone y,8
<br /> Contractor s;Nameg. arse No,: nt a
<br /> i'hone
<br /> y'> i, a
<br /> P
<br /> E OF: ELLLLr±Ir {+ORK
<br /> WELL AEPLA�
<br /> ijEW! WELL
<br /> TYP � �EMENT. 31ESTRUCYIOH
<br /> OTHE
<br /> a DiSTANLE;TO N£ARE.LT: SEPT1Cµ7ANicSTALLATTON SES+ERSLSNESFA[R L^I DI5P05ALRFLO P +,. aIf els
<br /> AGRICULTURE WELL ry; AOS, LINE.r„ -r..,
<br /> `rs }ir
<br /> FOUNDATION - _ 07H.A WILL �PtTSJSI rs
<br /> Y}; f r
<br /> 1 - - _ �.Tn - •?ter•'F'S ;!'4� "f�v� �'
<br /> rFg ! i INTENDED USE TYPE-OF WELL ,PROBLEM'AREA CONSTRUCTION.SDECiFICATiOEIS w y 1'a s @!
<br /> Ind�strialjti Open Bottom [ Manteca Dia. of Well Excavation $ 3;f rte— '
<br /> ' LrI J U Domestic/Private Cl Gravel Pack .Tracy Dia. of-Well Casing
<br /> Putr1"icl. Other Delta A
<br /> Cj © Type of tasin9
<br /> E k, ,IrrigatIon _ Approx. Eastern Specifications
<br /> [3SCathodit Protecttun Depth Depth of Grout-Seal
<br /> Grao�hysical', Type of Grout i r
<br /> i
<br /> Surface Seal Installed by71
<br /> h ' Repair Work Hone Q` Type of Pump State Work Done
<br /> We11 Destruction[] Well Diameter Sealing !iaterial (top:SO )
<br /> u= is
<br /> > , I
<br /> ..Depth 'Filler�.IMterlal1le_joW .,'"'xx•i'}'F!
<br /> y
<br /> y s ,`, �,p Rei __ R A001TION ( o septic,tank.or eepage pit perroi;fed If,.pIiie
<br /> TYPE/6FSEPT3C WORK, NEW INs, _LATIDN Lia `REPAIR/. F! . available rlith%100 feet�a
<br /> (' 9 1rAstallatYOn.wi11 Servence,. Commercial: Othee:.
<br /> Reslde
<br /> 0 - 41 •{" '' Y.;. " k `r dq 9:i`.ITr `' '.
<br /> ri vx "'Number of living units umb
<br /> Ner of bedrooms Lot size
<br /> Character of so to a `depth of:3 feet: Water tlYbl,e.dNpth ' t
<br /> 3 i; CaPaci.ty'� No, Compartmen s
<br /> _'. SEPTIC TANK Type/Mf
<br /> g a
<br /> yy PKG. TREAT?1ENT PLT. TYP=/Mf 9' _ Capacity Method of'rD,iSpasZiv
<br /> - _... .. z Property Line' -.,,
<br /> i s 'SEWAGE,.SYSTEM a, Distance to nearest: well Foundaiicn y� «--Wr- 'S-� s s
<br /> DESTRUCTION
<br /> LEACHING L1N£6°,y U No, 6 Length of lines
<br /> .� Tdtal length/size. O: { "
<br /> FILTER 8EO Q Distance to nearest;' Well
<br /> Foundation perty Line 31 k
<br /> Pro,
<br /> r.
<br /> Number r IF ti a u ' G1T , l
<br /> t 'z SEEPAGC PITS, ' Depth Size y_fry- ..
<br /> > ProF�rt Line 7Y`(J.,, 4e n
<br /> SUMPS; L_ Distance to nearest: Wall Foundat.lon ,� Y ,r,i u a
<br /> DISPOSAL PONDS ❑ a , `� '::. " T
<br /> hereby certify that I have prepared this application and that the work will be done>in ac .ordance with.San Joaquin couaityt i r1
<br /> ordinances, 'state laws, and,rules and regulations of the San Joaquin Local Health District— -;;
<br /> Hope.owner �r licensed agent's"signature certifies
<br /> such'mannernas to becomeysubfettRtOhwnrknxinScompens'ationwlew% 01 al;ifarnfd�"
<br /> Yi r PirolS,t is.,lssued, I shall not employ any person
<br /> + { � Cnntractor'sh'ring,or sub-contracting signature certifies the following:."[.,certify Lhat-in;the performanceof`LhedWorfbr Whieh ` Y
<br /> 1ql thls,,permitals issued, I shall employ Derson5 subject t0 workman's:compen5ation laws of Catifornla,"
<br /> p r t ? The:appl icant lus l l for all wired inspectin Ciimpl•ete.drawin'q on reverse side
<br /> r1 ' F
<br /> t Title:, Bate.,. y � ti
<br /> t i Signed Y
<br /> r 4 yr
<br /> n F DE ARTMENT USE ONLY / z
<br /> 5
<br /> ' +7�
<br /> Area
<br /> i. ea Stk 466c67
<br /> APAlitat,icn.Accepted t /•' �' ' Lodi 364+ 21
<br /> Additional Comments!. 823• l04� sa " `h
<br /> Manteca
<br /> Pit or Grout Inspection by �' ,3 �
<br /> 3sti}� r Final inspection by �� L�.t�+-^-1 Dat" �!' 1 [ Tracy, 8 •6 1
<br /> _�-,tet -
<br /> Applicant,-.Return all copies t0: .Enviieno?nta! gLalth'Rer61t/Servicesze►tan Ave., O Boy 2609 Stk CA 45241
<br /> BASE AMOUNT DUE Am,3 Nti REMITTEO _ aECEtVEO:Br DATE PE MIT NO i ..
<br /> A [NFO
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