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4. `...,.�Syy�j .x r ti , x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCK ON, CA r `P Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a7yp rsti� lk (Complete in Triplicate)for a _ i Application is heteby made to the San Joaquin Local Health District 549 for saws or permit 1862 for MrolUpu tip and the Rules/it install the and tReguWt ons of the Sa.li J q t made in compliance with San Joaquin County .>„ ,. t+r'" ,!' �• Local Health District. f¢ �b Citv� �Lot St:a r.wY7�--PM" Job Address t Ls ; +f `i �LYt hone Address Owner's Ndme } f's - �lPno ddress Icenst Nc. zy ; y • Contractor DES�RUCTION ❑ a�,`��t p! . 9 t e ¢;, F ; TYPE OF WELL/PUMP: W WELL ❑ NEWELL REPLACEMENT O fr�ZQr ,4 .,� OTHER'O SYSTEM REPAIR ❑ i+r PUMP INSTALLATION ❑ DISPOSAL FLD: ',PROP UNE f • Mt DISTANCE TO NEAREST: SEPTIC TANK EWER LINES { 6A ICULTURE L FOUNDATIONOTHER WELL aj}► t TYPE OF WELL PRODLEM A E CONSTRUCTION SPECIFICATIONS ti iurrr o r � INTENDED USE ;y,_ GltrW 1 ❑Open Bottom L,Mantec Dia.of Well Excavation 1 Dia of Walt r" ❑Industrial M t cT�rt R T of Casmg Speetfiutalts :� ao ❑Domestic/Private ❑Gravel Pack ❑Tr Type Type of GroJt tyr" �' r +' fl Other aha Depth of Grout Seal t 1t ? iii V (1 Public t - -I I Ivigation' to Dept Dept I I Eastern Surface Seal Installed by } _ - - .. H.P. State Work Dwta i w �t ��T� th 3 f f• ; f Repair Work Done (3 Type of Pump : +• i /M ¢ �y �J � Sealing Mat ial/top 50'1 _ � , w s rs Well Destruction ❑ Well Diameter —=-- Filler Material Ienlo' 1 1}tilt' Depth i 1 t TYPE OF SEPTIC WORK: till NEW INSTAL TION 1 REPAIR/ACOI flON D TRUCTION 1 I (No Nailablpatc thin m Dfe t1 Jed it twblie•t b 1�. / f 12 Commercial Other g ,,Installation Moll servo:. Resident: _ ft' t! Numbefjof living units: Number al bedrooms Water tsble'dattth r F - Character of sob to s depth of 3 feet: '= e`,��k� rtykl4� #dSau k Y _� CBpaCrty Nd.Ccmpattmelttf SEPTIC TANK ❑ .Type/Mfg--� '.Method of D PKG.TREATMENT PLT ❑ .PropeMUro earstc Well. "oundon Distance to nY H _ To Of length/size LEACHING LINE ❑ .No.8 Length of lines fc 0 Distance to nearest: . Wdl oundatlon �r" t ti C•k3 FILTER BED - • •- ,. . ., r,., •.-• is .:_, c�� Propeity ' `. Size NO6y w SEEPAGE;PIYo i II Depth � M PrnpertyLiMrtye �1> / .'Well-�I1ll— r^•atmdetion x..� is'l1 SUMPS 1 Ll Distance to no rear: 1 r+ r ; DISPOSAL PONDS c O r;i Ism �.. 1 hereby certify that i have prepared this application and that tho work will len done in accordance with San'IaagUinOunty ard`{nandtl"ateFtfer rules and regulations of the San Joaquin Local Health Diltrict: fs bai+od,I tlhM Nome owner or licensed agent's signature certifies the foarmir'tg:"1 certify that In the performance of the rork for whkh th(s pemllt employ any person in such manner as to become subject to workman's co mxnsadon leve of ed.CaliI hal ' ploy orso s subject or v�k�: r eanifles the following: 1 certify that to the performance oftthe work fo which this permit b rssusd I shall employ Demon i r ' <a y e rti Yron IoM a of California.'.'-,- 4` } z Ay'Y " a•r.ti �= Ths applfea must eaB} I reou: inspections.Complete Jrawtng on•riwrse akfe j3 �Vr a4t.rf,Ir` rn " i Sig t r,• - Title _ �! �• } i(t7�;° '� .d . FOR DEPARTME SEl ONLY , q - ? �,' ".•x`34:<!1•yS > 7 `r! - Ar Date777 - 1 sa ' y,C - - — lFj gr eatlon Acca- by isjDant^ Final Inspection bytit . y <t. '�rGrout Inspection by s r Additional Comments,` xf p �y+y ❑Stk 466.6761 ET L:iii 369.3621 ❑Manteca 823-71D4 ❑Tracy �5 `\\ Applicant,Return all copies to:Environmental Health Permit/Service 1601 E.Hazelton Ave.,P.O. ios 2009 Stk.,CA 652(11 \ 'tel j K PERMIT'NO, �•1 CA a RECEIVED BY DATE v + - INF AMOUNT DUE AMOUNT REMITTED 4(41 :-.�c •.EN I YII"EV. 111666 EM N-2a �S{"