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A:PLICATio`. r3R PERKIT <br /> SA'i JOAY'Uib LOCAL FFAL-F 71519:0 <br /> 1601 F. HAZELTOr, AVE­ 570CKTON, CA PERM:T NO. _ <br /> Telephone (209-1 4c6478:• <br /> DATE 155'JE0 _ <br /> PcRR1T ER=IP.=S 1 YEAq %ROM. D^TL ISSJ[D <br /> ,'Coa:ilete in Trlplicat0 <br /> Appiicntton is heresy made to thei•San Jodquir• Local Heait• District for a permit to construct and/or install the work herein <br /> descri am. TMs application is made in comDlla ce with Sari Joeauin Ccunty Ordinance No, 549 for sewage er No. 1862 for well/Pump <br /> and the Rules,and Regu�q rfl _Ql then Jt] }I ocefi i-ealtn District. <br /> O•05 Address_ _ L f'ljC-jWZjZof,%hdi0sion Name <br /> Owner's Mame Address _1, �_ _ <br /> Phones <br /> Contractor's Name _ license NO. i L ?hone <br /> TYPE_OF_k'E_L/PUMP 1404K.: NEW WELL ❑ WELL REa-ACE1147 DESTRUCTIOF. ❑ <br /> PUMP INS-ALLATION SYSTEM REPAII l_1 OTHER I❑ <br /> ! <br /> DLSTAhCE TO 9EARES7: SEPT:C TANK SE'rtER LI?IS5 - DISPOSAL =L030?. :.:NEC. <br /> FOUF,DATIOY _A3RICIP:.TUR= WILL _OTHER ',JELL FI'S/".PS I.i <br /> INTEN]ED USE TY7_ Of WELL PnBLEV AREA CCNSTRLXTION SPECIFICATIM <br /> I findustr°.al ❑open Bottom r Manteca Dia, of Neil Excavation _ <br /> ❑iomest'c/Private C1 Gravel Pack Cl Tracy Dia. of Well Castny <br /> ❑Public Other ❑Delta Type e` Casinc <br /> j_] Irrigation Depth <br /> prox. ❑Eastern Specifications _ <br /> [f CdthodiG Protection p Depth of Grout-Seal <br /> ❑Geophysical Type 0• Grout <br /> Other Surface Seal Installed by <br /> Repair Worir Done ❑ Type of dusty .�f —Ii.P. --- State Work Cone _ <br /> Well Destrrction ❑ Wet diameter Sealing vaterial (top 50') -- -- <br /> F:11cr Naterial {Bel Ow 50') <br /> Depth � .._ ... <br /> LA <br /> se <br /> I TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIitjA3DiW.ON..{_j {No septic tank or sen>age p'avdilableewitnid if ny200cfert} is <br /> i Installation will serve: Residence Counercial _ Other <br /> - <br /> +lumber of living units: dumber of bedrooms - Lot size <br /> Character or soil to a depth of 3 feet: ��• Water table depth <br /> SEPTIC TA`lt 0 Type/Mfg Capacity No. Cpaoartments <br /> PKG, TREATMENT PLT. ❑ Type/MIFg Capacity Method of Disposal <br /> i StuAGE SYSTEM Distance to nraresL: dell Foundation Property Line <br /> DESTRUCT EON <br /> _ <br /> LEACN'1% LiNE IJ No, &'Length of lines ___-- Total length/size <br /> FILTER BED ❑ D:stance to nearest: Well =Foundation ` _T Property Line _ <br /> SEEPAGE ?ITS ! Deptn Size -^�`Y Num _ l _ <br /> SUMPS U Di Stance to nearesL�Wel.l•� •=aundatlon Property Line <br /> DISPOSAL PONDS <br /> ,,- <br /> I hereby certi4y that I have prepared this aiiplization ar.d that thy work will oe done in accordance with Scan Joaquin county <br /> prdinances, state laws, and rules a"•d regulatiuns of the ia-. Joaquin .opal Hea',ttn Cistrict, <br /> Home owner or li:grsed agent's signature certifies the 'ollowing: "1 certi`y that in the performance of the work for wi,ich this <br /> F perr-At. is issued, 1 shall not employ any pursnn in such -canner as to become sat ofecc to at it the <br /> card radon low-, of rrk fornia." <br /> Contracicr's hiring or sob.contracting Signature certifieS the fnllc.,ding: "I certify that it the perfcrmante of the work for which <br /> this eriit is issued, I shall employ persnps s.jbject to workman's compensation laws of Califarnia." <br /> r the applicar St call r a1 Gu P n cions. ConIe d b e' <br /> f Ilia: Date: <br /> Signed K �' " <br /> ! r FCR 'ART SECT USE ONLYE]area — ctk 46S-6)81 <br /> i Aa•ptication Accepted by" <br /> Lodi <br /> Additional Ccr,nents: ,_ 339-3i;?1 <br /> r Fit or Grout Inspection __ :Ute _ MM nteca 923-1101 <br /> f Final Inspection bydftNh ,,,.,,�_ Date "i .racy 1335-6385 <br /> - Return all copies to: Er•.d'rormental Hea-10- Permit/Services 1601 E. Ha2eltCn Ave., P.O. Box 2009,1 Stk., CA 55201 <br /> . Applicant _. _ ✓✓�� <br /> FE. BASE AIiCdNT OdE SAMOUNT RE"ITTEC CEII'ED BY ,+OA.TE _ _ FE-RMI.1,.h0. <br /> INFO <br /> = 10I S27513 J <br /> i,I 13-24 RLY. 1C/82 <br /> 14-26 ,. <br />