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I APPLICATION FOR PERMIT
<br /> SAN JOAQUI14 LOCAL`HEALTH DISTRICT
<br /> 1601 E. HAZELTON AVE., STOCKTON, CA
<br /> I Telephone (209) 466-6*1'
<br /> f PERMIT EXPIRESA AA'R-FROM-'DATE 18StlED�E'
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<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein.�t' :7...•'.:'H._�.;a-
<br /> described.This application is
<br /> made in compliance with San Joaquin County Ordinance No.W for sewage No. 1862 for well/pump and the.Ryles and Regulations of the Sart Joaquin
<br /> -Local Health District. 3Lav« .. c ?{ �. =f., - V1 _
<br /> Job Address `//LN L i< s 4 e P•y .{r:.l++ A �
<br /> City Lot Siie ply '
<br /> Owner's Name' =��'.y�QaJ Jl'l�'t//Er2%A Address.,.—
<br /> �} Phone
<br /> Contractor �.�.
<br /> Address J License Nola-_91F_�Ia Phone
<br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ 3
<br /> .PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ . OTHER ❑
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE i
<br /> FOUNDATION*, _ AGRICULTURE WELL OTHER WELL PITS/Su PS
<br /> ``'",INTENDED USE ` .� x<. �:,I - s :.,
<br /> _ TYPE OF WELL PROBLEMARFA CONSTRUCTION SPECIFICATIONS
<br /> ❑ Industrial ,,�,�❑.,Op�.Bottom Manteca Dia. of Well Excaikiort "t `
<br /> '. t `
<br /> 1 .oi Well Casing
<br /> C Domestic/Private ❑ Gravel Pack El Tracy Type of Casing v � ti• Specifications •,
<br /> C Public ' ❑ Other " •` •.•�I. , Y�\ ,,, i •s ,r-i
<br /> ❑ Delta ,•Depth of Gro_ut'Seal " 1
<br /> �C Irrigation r -_A - lYPe of Grdut '
<br /> �. , pprox. Depth ❑ Eastern �'�."Surface Se aldnstalled:by,`t -.1 t;
<br /> ReI it-Work Done ❑ _Type of Pump t H.P. `- '
<br /> State.Work Done _N
<br /> Well Destruction 1�L,'W fell_Diameter 4 Sealing Material(top 50') �'�
<br /> l Depths_ - Filler Material (Below 601)
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-L.1 REPAIR/ADDITIONV DESTRUCTION ❑ (No septic system permitted,if'public,sewer is Vn
<br /> e - available within 200 feet.) ., S
<br /> Installation will serve: Residence Commercial— Other r (JI
<br /> *, Nnmber of living units: Number of bedrooms
<br /> Character of soil to a depth of 3 feet:. f
<br /> 2 pTIC 7A1VK s Water table depth ``��
<br /> F. Type/Mfgi�. Capacity /-,4?:Qp No. Compartments r
<br /> PKG:,.TREATMENT'PLT.❑ y• �' r, r `
<br /> �• l / �7- Method of Disposal
<br /> t� Distance to nearest:. Well. I Foundation� Property Line
<br /> i F r
<br /> LEACHING LINE J"' 0 No. &Length of lines P� e I"
<br /> Total length/size 1111
<br /> FILTER BED ❑ Distance to nearest: Well Foundation_ Property,Line
<br /> SEEPAGE PITS 13"Depth~- 'f Size' Number
<br /> SUMPS r.- wr ❑ Distance to nearest WPI F ndation �"t••u% b Pro
<br /> tit��.. y t - -Egu party Li ^ i
<br /> '.DISPOSAL PONDS C a. ,
<br /> 11 L
<br /> I hereby certify that I have prepared this application and that the work-will be done in acco_rdaricetivith San Joaqui county ordinances,state laws, and
<br /> rules and regulations of the'San Joaquin Local Health District.Z, ,}i,;,. '
<br /> ,Home owner.cW licensed agent's signature certifies the foAowin "I certify x r `' f
<br /> g:, rtify that in•the performance DI'the work for wh Fh this permit is issued,I shall not +I
<br /> employ any person in such manner as to be nne dubject to workman's colipensation lav of Califomia;contractor's luring or sub-contracting signature
<br /> certifies the following:*"I ceFtify that in the performance of the work for which this
<br /> `tion laws of California." j r� j ; ! permit s issued,1 shall employ persons�ubject to workrtran's compensa- S
<br /> The applicant must call forfall aired.n
<br /> spectlons. Complete drawing on reverse side.
<br /> Signed X /r• ... ' /,r , +5'r
<br /> =^"ET'i�tle".!a...i. � .•� _ A
<br /> Date'i1_
<br /> FOR DEPAR ENTtUSE ONLY '/��
<br /> Application Accepted'by / :/ 7 7 ,
<br /> Date Area
<br /> Pit Ar Grout Inspeion by
<br /> Date Final_. nspection by VDateJ �
<br /> Addition! Comments: r� � .
<br /> ❑.Stk 466-6781 ❑ Lodi .36&3821 ❑ Manteca 823-71Q4 ❑Tracy 8356385
<br /> Applicant- Return all copies to: Environmental Health Permk/Se'rvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201
<br /> f
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<br /> AiFiIOGNT DGE AMOt7NT REMITTED '«ASH _
<br /> « -•-�yt� RECEIVED HY DATE PERMIT`NO.'-'•'Y
<br /> t`EM-13,29(REV:v185) � 1fJC/— y.= -.e... ��.,,L —.:_•.,�,� a .F s
<br /> Ek 14.26 ._ `;'•'^-.••".".'"""`�... ."..".. ^�• .
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