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APPLICATIi3ll f" #iERfllllT SAN JOAQUIN L06AL.WCALN bigtAlct tsAVM P-t4T % i6v 1641 E. HAALTON AVEC; STOCktON; CA i TeleOk6hd WO0 466-67$1 - MAR 2 11041 II7 i=XPIRES,I:VEA i IFl*OIVI I AT �SSUi=i] } . ,• • iComplet3 in triplicate) HALH Application is heletiy rtiade to the San Joaquih Lec31 Heahh Di5irict fora peimitit to consliuct'and/ot fnstaH the work herein '*@kms#J%W�p�tion is j made in compllancr;with SAh Joaquin Couhtq Ordinance Nti.649 0 his vagi}of Nd. 1862 foi well/hump and the Rules end itegulation3 of the SAn Joaquin Local Health District. I' - ' s` •-�-%z 'cure - Job Address 9/60 �t or,Yl>�7I� /�oa�cl. ', _,; ".City, x� c{` - Loi Size PM F' Owner's Neme So�e#G�czvi f f Address Zo $Ie►7tfa. twit 1�, " PIea54Ui�nb YKE 03-K-7/1 Sfrrha� ctCtiX� biu:sro►t df' - y l� G7 0 3 .3 238 o Y a( 8 . 't rJ..'C014"rd C 3 h6t 'r/ /� /f License No. i Coniractar �-T•Pr�+:�.k�Jalift" Fes' �d�ess .,� ,,.,. _. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT-0 DESTRUCTION ❑ E PUMP INStALLAtIi]N [l j 4 SYStE lVI I$E PAIR " I OTHER O DISTANCE TO NEAREST: SEFtIC TANK l: + SEWI F# L1NE5 { �� ` *- b15 PRDP• tINE FOUNDATION e A016ULTEIRE WELL ONWELL 6 PITS/SUMPS INTENDED USE,• TYPE OP;.WkL i""t; PitORLEM AREA r 1 CONSF�iIJCtlO PECIPIC 71O r # h s / i 1 sii['A Dib S Sf Well Caw x ❑ Industrial � Opan Bottoiri i El -� , •-� bla: of We11 Ex"aJ t2 � DomCes�j !Pt" tB eGravbi Pack D Tracy � tyfle oi, asing ✓ 1 ✓tA:�(O Specillcatiom t ! lie t n olpbr t"dlta bot" df out " o, rk 1le. Type 51 ibiit yf/t*A[etNttc E 1 Irrigation = T sp.Approir: bepth I I Fasieiii r ,..'..Suri a Se I iir'stall Gtb tL � rerli►�ol dyes rise: t Repair Work Done C] Type of Pump Ae- H.P. } die - o Doric r - i Mefti/tt Well Destruction r ❑ Well' l3ihnieter Z r� _ j 5e M e W It 50'1 G il{' 1 /164r� C r' f•- u ([ 9 Depth E. 5��.: _-- PIII r Ma rf i 8efo 50'1 TYPE OF SEPTIC WORK; NEW INSTALLATION I:I REPAIR DD 10 I I DESTR TION I I;iNo septic syste permitted it public Sewer Is 1 available 4Yithfn 2 feet.) ° �! Iristallatlon Mil 'serve: Residence_ Cornrne fall Oth ' Number of living units: Nurtihaf bf be hs i Character bi soli to A depth of 3 feet:' Mg, ' w Water table pili i SEPTIC tANk [3, Type/Mig Capacity No. Coriipart `n1S PKG.KG. TREATMENT PLt. ❑ ' 4 f Method of bi 'osal I1 Dlstaiict3 fe tiearM . Well. Fottritfatir5ii'" Pfiip6rfy.Ltlie ` I LEACHING LINE ❑ No. & Ubdifi bf hikes total wl3igth/si2e I FILTER BED ❑• 131statict~ tii heafest: )Kelt ' kbu�Hatioii ;{iropeitY Line . h SEEPAGE PIIS I,1 bepth i i € Siza 1 i Nu66r m' SUMPS d- bistaitcd to Nearest: Weil" Fbiirtiiatiori I•-*••- Property Line blSPOSAL PONDS-0.,❑. '.m::- �, +-, r. - _ _:;.-. ci.1.: F- ,. o :I I hereby cartifY that i hilve prr?Oi fed ikle applicdil6►aiid that the Wbvo will bg-dohe In 666,&��licft With Safi Jbaduili t bit fyi 8 1iieFicn , IiEafe IailfiA, Grit#X,4;3` rules and regulation's of the San Joaquin L&cal lfealih bi3trict. Home owner or li6ent;9d babnt'§sighfit'W6 certifies the follci%Mhg: "I ceitifY thiif in the Orforrriafice 61 thi work for Mick this pe i i3 l9iiM, I ffiall not•yl employ any persoA in"such tt%ahher as to becorv%iiubject to workmen%coft6Astloh hI% &4 of CbhWhia."Cbhfractoi s hiring 8r oiiiraeting Ndmiture { certifies the following: "I certify that in thb performahce of the%York fol which this permit is lasudd, I shall Mnplov persons 4ubjeEt orkr'ti8h'a cbmpbnse- I I tion laws of Califatnio." 'rhe applicant Md9t gall for a wired ihspectiohs. Complete draurin8 oit r9WW side. ' y Signed X title:/"� �Dlaft3�I bat -77 e: EOfi bEPARtMitNt USE ONLY � x , Applicatloh kccepteri 6, i 1 bate Area Pit or Grout 111-s0ectinri by- ; t]e`te Final Iiispectioh by barn Additionill Corrirndhte: I + n r ❑ Stk 468."1 ' ❑ Lodl 369-3821 '❑ Mshte6a W-if64 4 +CI Tracy • 835.8385 Applicant- fl;eturn"ttli Coplei to: EnJirbnmehigI Health Permititetvfcatt 1501 L.!Nazslt6fii A-va.; p.O,9oR 2oo9l, Stk.,, CA btldi IFEE NFO AMOUNT IjUg AIJIOuNt RE6Afrti_n c t1 ` htuivin AV BATE PtR__M-T'N0. . EH 13-14(Arv.t y q bs + 1 i EH t4-29 r1 f .