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For/,. a <br /> APPLICATION FOR PERMIT _ <br /> SANQUIN LOCAL'HEALTH DISTRICT <br />(' 1901_E. HAZeLTON AVE., S'l 0(;K l'UN, CA r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> ICOMPIAtA in Triplicate) <br /> Application is hereby rade to the San Joaquin Local Health District for s permit to construct and/or install the Lrk herein described.This application is <br /> made in compliance with San Joaquin County Ordinance Nn. PAR fn►saw9n or N 1862 for wall/pump and Aho I lulww and RegularIons of the$an,foat3uin <br /> Local Health District <br /> r �?p ParV.-I # 137-020-31 <br /> Job Address Ififfi BaClfig AYM Lot ' e PITA <br /> Owner's Name U=a1 C=atlon Address Pr / Phoria <br /> conlractor_Mjyne Drilling Addressp•0• BOX 726 Li ' i. ► e o. 3 345 Phony 91 E <br /> _TYPE OF WELLIPUMP: NEW WELL (X-�W WFIIII�REPL w DESTnv TION 0 V <br /> PUMP INSTALLATION r] 'q�I 'Ry YST !0THFA <br /> THER 1A1j�QgL.�C'NfL x!9(iyDISTANCE TO NEAREST: SEPTIC TANK �likMER _ JGAL PLO.. PROP. LINt 3�FOUNDATION AGR1 ULTURE WELL WELL / 'r PITSISUMPS�J)4 <br /> INTENDED USE TYPE OF WELL PROaLEM AREA t;UN5TRUCTION SPECIFICATIONS ,, <br /> iI industrial C1 Open Bottom G Manteca Dia. of Well Excavation LDia. of Well Casing 2'I <br /> G Domaatic/f'rivate 0 Gravel Prck CI Tracy Type of Casing Specifications <br /> Ml Public X1 Other Sarld PaC( IA DNtaStoCktpn Depth of Grout Seal 401 Z10i D I Tyne of Grout Nffit <br /> I I Irrigation �,l 65 Approx. Depth l 1 Pastern Surface Soul Installed by 11er' <br /> Repair Work Done C_`J—"ype of Pump NA H.P.,_ State Work Done <br /> Wall Destruction O Wed Olamem mit +�W Sealing Material{top 50') <br /> "Miitxirlg Wel l Depth Filar Material (Below 50') <br /> TYPE OF SEPTIC WORK: NLW INS I ALLATION 1 I REPAt /ADDITION I I DESTRUCTION 1 I .(No septic stern perfnitred if public sewer is <br /> aveilahle nii hin 200 feel.1. <br /> Installation will&Arica: Raaidgnae_ Commercial Othot <br /> Number of living unite Number of bedrooms <br /> Charnntar of toll to a depth of 3 foot= Wath table depth <br /> SEPTIC TANK 0 Type/Mfg Caoecity No. Cpartments <br /> PKG. TREATMENT PUT.❑ Meth o1 Disposal � <br /> Distance to nearest: Well _ Foundation Property Lin <br /> LEACHING LINE .4 fl No. & Length of lines „ Total length/site _ <br /> FILTER BED CJ Dlstanc0 to nearest: Wes Foundation Property Lin <br /> SEEPAGE PITS I I Depth~ Size_ Number <br /> SUMPS 0 Distance to neeraat: Well Foundation. Property Lin <br /> OISPOOPAL PONDS n <br /> I hereby certify that I have prepared this application end that the work will be done in wordance with San Jn cotrnty ordia*nrsma, atata iaws, end <br /> rnl■a and raqulstlona of the Can Joaquin Local Hearth Dlktrict. <br /> Horne owner or Ikonsed agent's signature conifies the following: "I certify that in the porformance of the work fo which the'pernit is iswsd, 1 shop not <br /> any y porton in such maitre as to become subject to workman's Cornpenaat'inn laws of California."Controc ea'hirinq car autr-contratting tlgriature <br /> sertdise the foaowing:"I certify that in the performance of the work for which this permit is issued,f shop employ pi room subject to workman's comperiu. <br /> tion Laws of California." <br /> Tho applioant utl far aI1 r uirp{f inn Ilona. Complete drawing on reverse side. <br /> f Signed X,c- �9i� t,.r _ Title:,�. Date; <br /> Acrd--fix 4Jc Or�uFOR DEPARTMENT USE ONLY <br /> Application Accepted try Pats '2� v A. <br /> Pit or Grout tn"Painn by Date "2 Ffnat Inspection by Date <br /> Additionbl Comments: <br /> O t3tk 405.11"1 D Walt 3t-3121 O Manteca UM-7104 0 Tracy 836.838.5 <br /> Applicant• Return AN copies to: Environmentel Health Parmit/Services 1001 E. Hasolton Ave., P.O. Box 2009, St ., CA 95201 <br /> e,f, <br /> FEE•. AM)U1T DVH AMOUNT RERTTED <br /> �INFO . !I� <br /> EN 1;H IEVria sr Ektre t/. 92-1931111 <br /> ". 1 <br />