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�> `•� APPLICATION FOR PERMIT f 4. « 'SAN JOAaU1N LOCAL HEOLLTH DISTRICT 1601 E. Ff, E, `b `AVE TOCKTON'CA + `} Tel phone t +09i k i } PERMIT EXPIRESA 1 ARTR M=DAT ISSUED'> f �Camp�eta m Thp :Mkt `" - - k:.•;x r:,, � } � ,.a -.- ,_ 1 v - r c`•q'I. 4p 11cation'fs hereby made to the San Joaquin Loch Hsetth District fur a permit m... cf,and/oc,h>st l ths.work made in corn nce with San J n !d Thk plie oequln Coun Ordinance No 648 for or No BB2 3 `Firiaith` flet " ; p - fur wsAlpump and the Rules and Regulations of titre Sen Jaaqukm ' r ` _.Y -.. -. ,�vi S.,� �� d �§� v+. .` s; !-.r!,i 9 �. xt`:�t� 3 ti 4 ;s. -♦ Y . ;C:.,, ' Y ;'if-1,r..x� `.Z• f a-,1v`io -<: 1ti ¢ '�'r `:. In «r ° 1� E "fdx :,1T Job Address i"S11/ CJ�g�in F' 3tti x r 1�4fi'7�#�s`�+WtSlza ' rF ' s ' tet � #�� ap �3s,1 a s ,.t Ownei'e Name _" Cr 41t" �� .. 155 ?o2Y� ; ContractsAddress i= License No: F'li y TYPE LOF WELL/PUMP: NEW WELL.W WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO.NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 5 FOUNDATION: AGRICULTURE WELL OTHER WELL-"� PITS/SUMPS ..INIVNDED USE ; "TYPE OF WELL - PROBLEM AREA' CONSTRU ION SPECIFICATIONS 0-Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Die of Well Casing r ❑DonmeaUc/Private �LI:Gramrel'Pack ❑ Tracy Type of Caai: 0 g p-PUNIC 0 Other ❑ Dela Depth of Grout Seal. .Type of Grout [7 Irrigation +*t:Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑. Type of Pump W.P. State Work Done Well-Destruction. ❑ Well Diameter �2 01 _ Sealing Matwial'Itap l HoAt11 f bJCI� Depth <e2.:.. Filler Material(Below') F SEPTIC WORK NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if publie.sewer- available,withir 20Q.feet.l _ Installation will se Residence Commercial _ Other Number of living units: umber of bedrooms' Character of soil to a depth of 3 feet: s " table dePthh SEPTIC TANK ❑ --Type/Mfg, Pam ItyNo. Comparnnants. ' PKG. TREATMENT PLT. ❑ Method of Disposal Pistafice to nearest: Well tion Property Una LEACHING LINE ❑ No. & Length of lines ngth/size FILTER SED Cl Distance to Well Foundation P Line SEEPAGE PITS. Depth Size SUMPS ❑ Distance to nearest: Wel! FoundatiaProperty Line AL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature cartifies the following: "1 certify that in the performance of the work for which this'permit Is issued,1 shall,.not employ any person in such manner as to become subject to workman's compensation laws of CalHomia."Contractor's hiring or sub-contracting signature certifies the following:"I certify that In the performance of the work for which this permit is Issued,1 shall employ persons subject to'workman's coinpense- tion laws of Callfomia." The applicant must Call for all fired in s. Complete drawing on reverse side. a/kc 0;%C ,4&d Signed Title: Date: .3 ok:�iVIS� E US ONLY - Application Accepted by Date 'Area Pit or Grout Inspac' j A"�.` Date- !=j 11"Inal 11 mpection by D Additional Comments: } ❑ Stk 488-Ml ❑ Lod! 389-WI ❑ Manteca 823-7104 ❑ Tracy 8355-aMi Applicant- Return all copiaa to: Environmental Health Permit/Services 1001 E. Hszelton ve., P.O. Box 2009,Sfk., CA 95201 Q. FEE AMOUNT DUE AMOUNT REMITTED RECEMO BY DATE PERMIT'NO. INFOwe CASH a EN1}24fREV.1/651 H 14 E -26