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APPLTCA-104 FOR PERMIT SAN KMIJiN LOCAI 1F.4LT1 CTSTk1CT , q- 1601 E. HAZFLTON AVE,, STX..KTON, CA. FFRMI' VO, r Telephorp ('09) 466-670) DATE 1SSLED PFRN:T EXPIRES 1 Y---AR FRCv DATE ISSUED (Complete in 7ri3licate) aoplicatcon Is hereuy made to the San Joaquin Local Health District 'or a pen0t to construct andror install the work Ferein ' des crioed, This application 4s made -r ComP110CC with San Joaquin County Ordinance No. 449 fnr �ewace or Vo- 1562 for wellipump and the Rules and P.equlatior,s of the San naquin Local Health District. Job Addres5X2,4M Subdiv•sion Nai-e Owner's Na11F I& ► _ address 13 9 L/�/�G(. __ Pi oris Contractor's Name C& !DDLlcens: No. A42/ Y P'r'` It 4279-ate -YP- OF -WELL/PUMP A'OR.C: RiW WE'.L Cg W£L'.. REPLACEMENT [] DISTRUCTION PJMP INSTALLATION F1 SYSTEM REPAIR LI OTHER DISTANCE 7C, NEAREST:SEPTIC TANK dao f- SEWER L'NES _— D.SPV-61- FLn, 10VIL—PROP. LIKE FOLKGA-ION AoRICLLTI-RE WELL �� T-HER KEL1. .. PITSISUMPS 1NIENDLU USE TYPE Or WELL PP•3HLFY .RFA CrASTR'JCTiCA SPECIFICAT:LNNS 1 ri I_jlndustrial EJ Opdn Bottom D Manteca Dia. of Well Excavation onestic Privar.e Gravel Pack 1�Tracy Dia, of Wel' Casing _ _— 77 Dubl:c �jOther U Delta - �y;e of Casinq —vC--ff.4 e i`j irrigation �Approx, CJ Eastern . ^athod c ProtectionDe7th raP'tificallons 00-pt1 of Grout teal L 5eopnysical Type of Grout HhQ!N�j'T�. LI Other Sl;rface Seal Installed by Repair Horl. Donn Type Df Funo H.P. m- _— State Work Done _ Well Destruction iJ M'r_Il Diameter `— Sealing ''atcrial (tap 50') �_— Depth Filler Material ?Below 50'1 _ TYPE OF SEPTIC WORK: NEW INS-AL.LATION U REP-J R/ADOITIO.N I._1 (I.: septic lar'. or seepage p•t permitted it qublic ;ewe), s I available withic 2D] feEt.) i- Installation will serve: Residence Cnnmercial Cher CiU "lumber o° living units: Number of bedroom Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TAVK F— Type/P.fg — Canacity No. Compartments — PKG. TQEATMU"! PLT. [] Type/Mfr Capacity Methad cf Disposal — SEWAGE SYSTEM Distance to nearest: Well foundation Property Line OESiRUCTIOII LEACHING LINE U No. S I.cngtn of 1incs Total length/size Til-TER RED - [] - Gistarce to nearest: .dell _ _ - Foundation r _ Property Line SEEPAGE BITS Depth Size _— Number SUPS U Distance to nearest: well loundatiun — hrop,:rty line _ DISPOSAL PONDS I hereby certify that I have prepared this apolicanon and cha, the work wl.1 he. done in accordance with San �-uanuin county ordinances. state. laws, and rules and regulations of the San ioaGuin '.ocal Healt'', District. 1•.Cme owier or licensed agent's siurature certifies the following: -I certify that in ti,.e. performance of the work for which this per-lit Is issued, I shall not employ any person in such manner as to beccwe subject to workrank ecrpensai.irrn laws of CaliForria." Contractor's hiring Or sub-cartracting signature certifies the followinq: "I certify that is tee performance of Lie work fnr• wfi-ch f„ this Cerrrit is i5su d, I shall employ persons s.ibiect to wori-ton's t_ompensation laws of Californ10, The dppiican . t i3ll f Lill reTuired inspec'-ions. Complete dr ng on verse s--d /mow Signed X Title: Drte: — �//i•J -- PARTMENT USE 0140 Stk 466-5181 ApA ication Accepted by —_ J .� AGditiona. Counaents: _ [, Lodi 369-3621 Pit. or Grout inspection by _ Ca:e � Manteca 823-1104 final Inspection by _ - Do'.e _ Tracy 835-6385 4ppiicant - Return all copies to: EnvirorimenLdl health Permit/Servirr< :GCI L. Ilazelton Ave.,, PP.D.�nx 20009. S'k-, ;A 45201 rFEC BASE aM7l1NT DUE AMOUNT RFMIrTtU - —iEfl BY , DATE I PLRMTT NO. fO —'�j r- — 1-3 -� . 1 — EH 13-24 REV. 10110' 13182 SCO 14-25