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<br /> APPL1ICATION FOR PERMIT � Maw, r�
<br /> (OiAN JOAGON LOCAL HEALTH DISTWT � � �� I,
<br /> 1601 E. HAZEL T ON WAVE„ Sl OCKTON, CA .
<br /> Telephone (209) 466-6781
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4
<br /> (Complete in Tdp)icatel
<br /> AvoliCation is hereby made to the San Jouquirr Lucal Health District for a permit to construct and/or install the wr,,rk herein described. This 6ppQcmtinn is
<br /> matin in cornpli:ince with Sart Jo3QUin County Ordinance No, 549 lot sewage or No. 18G2 for well/ptimp and the"I"and N09111atinrta of rho Serr Juayuut
<br /> LoCal Heats, District,
<br /> Job Address --- y t/ _ -�7 .` ' ..-_-- t:rry ._�O 4 I nt PM
<br /> Owner's Namo Mr. Mark.fe_...k.(e{CA _ Address q,W.e_ �.LX �T..• �� Phone —Qt
<br /> ii 44 LL
<br /> CorttrdGtor, �I�I rft{IY1 7G17Qfr1,.AdCicssI..irenseNu. 4(00 Phon �� 1��•I� 1
<br /> TYPE OF WELL/PUMP., . NEW WELL WELL REPtAr.FMFNT Ii DESTRUCTI0N r]
<br /> _ PUMP INSTALLATION Cl SYSTEM REEFAAIA U 011 HEN D
<br /> DISTANCE TO NEAREST;
<br /> SEPTIC TANK SEWER LINES �}�.` . DIyPOSAL FLD. ,;_ PROP, LINE
<br /> - FOUNDATION -___� � AGRICULTURE:WELL OTHER WELL PITSlSUMPS
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> U Industrial ❑ OpCft Bottom 0 MairtoCa Dib, of W.lI Excavation_- _L niP. of Wn1! f 9rinrJ
<br /> Lz Durr►estic/Private Gravel Pack L.ITracy Type of Casing'. '< Pve, —_ Specifications he-Oct _
<br /> 1'i Public n Other n Delta Depth of(iron) Seal _1. _ Type of Gro,rt ?
<br /> 1.1 Lrrigattun 70-Appiro r. Depth I. I )astern Surluuo Sued Installed by
<br /> 0 Type Of
<br /> Well
<br /> Repair
<br /> Destruc[fon @ fl Wolf Diameter .� SC&liar Mareriaf (top �'1' 'State Work Dane • �- —4 _ _
<br /> �.. .
<br /> �t� t _ J p s
<br /> MOV1lisr't W�l1 Depth — r - Filler Material (below 501 J. j
<br /> TYPE OF SEUIC WORK; NEW INSTALLATION 11 Ftl'PAIR/ADOITtON I I OLSMUCTIoN I I (Nrf seslrtir. system permitted if publie;'sewor is
<br /> i k available within 260 feet.)
<br /> x ,
<br /> Installation will serve: Residence— Commercial ...___ Other--
<br /> Number of living units: —_— Number of bedrooms_........... , 4 +
<br /> C118rgCtpr of sail to a depth of 9 feet. -....,_._.._,__-___.___. Water tublO
<br /> SEPTIC TANK n Type/Mfg „ CSpacrty __._. Nn. Compartments _
<br /> PKG. TREATMENT PLT, U Method of Disposal
<br /> Distance to nearest: Well ,__..,._ `Foundation •, _ property Lint; -..
<br /> z ,
<br /> LEACHING l.tNE-_.....-. Ll _., ...;.. . .._.. :.—... _ _.___.—.__....... . - ,
<br /> .. No. Br Length of lines _ ; }- Total lenrlthlitize.. ..
<br /> 'FILTER BED LI Distance to nearest: Well FoundationProperty Linn
<br /> ts .l ..._..
<br /> SEEPAOE PITS ) I 00pth _ Sire _.;— Numher
<br /> SUMPS Ll Oistence to nearest: Wclt fx,irr,rr3rirm —_ Property Lina
<br /> DISPOSAI. PONDS — U
<br /> I hereby certify that I have preparelrf this application and that the wnrk wilt bet done in'a,:cordance with San Joaquin county ordinances, state laws, and
<br /> rules and regulations of the San Joaquin Local Health District,
<br /> Home owner or licensed agent's signature certifias the fallowing: "I Certify that in the performance of the work for which this permit is issued, I shall not
<br /> employ any person in such manner as to become subject to workman's rompetnsatinn Idws of California."Contractor's hiring or sub-contracting signature
<br /> certifies the following; ")Certify that in the perforitiarlCe of the work for which this-permit is issuud,i shall ernpluy Demons subject to workman's Gnmpenba-
<br /> tion laws of California," �_ -
<br /> The appii nt at call f 11 rea fired inspections: Complote drawing on reverse side. p. f
<br /> Signed X ,. _ SeA'GO�. Title:, fn i G�, 6¢6i5'IL .R-6.4�4q31_-. hate: _..._� .ph.i,.
<br /> FOR DEPARTMENT USE ONLY
<br /> Application Accepted by .,.__. __..____� pate Area -NIG
<br /> --- L" 1
<br /> Pit or Grout Inspection by Oate—_ Final Inspoction by _—.— Date
<br /> Additional Comments: _
<br /> Ft Stk 466.8761 0 Lodi 369-3621 0 Manteca 823.7144 0 Tracy 835.8385
<br /> Applicant - Return all copies to: Environmental Health Permit/Services 16011 E, Hatelion Ave., P.O. Bax 200,9, Stk., CA 95201
<br /> FEE AMOUNT DUE--.- AMOUNT REMitT60 CK k FtE mAr) eY DATE PERMIT'NO,
<br /> INFO
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<br /> i 2441
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