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''_k APPLICATION�I�O PERMIT ; R f
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<br /> SAN JOAQUIN.LOCAL WEALTH DISTRICT
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<br /> �- 1601 E. HAZELTON:AVE. TOCKTON,.CA -}
<br /> Telephone:(209)', 81
<br /> PI"RMIT•EXPIRES VYEARFF OM DATE ISSUED"F , F ��rf� r ? =fs��ik;�its s
<br /> EB .':--,k'°3t` t3N,C15 -fir tri �ia} ti•:.:1. - a. - - _ -... L a t4
<br /> Adv 9'`s- %- i' lr...•,.8.} yy�, a, y e
<br /> (Cornpif3le,in TrI Irc�tel `-
<br /> �atryl�xitf, ,`'43 Rti'� k' - s1 s s
<br /> AppNpttion�s hprspy made(tr►hthet rna ioatZtrin.Rpoel;Health Diatriet for e,perrr,it t9 corrstrtac;and/orr,inataA ttie,w rkjtta�airt.4 albedo.,°Chis appdeatbn iar
<br /> made in'compiianee vrtth San Jtiaquln County Ordiryartce No 649 for.sewwage or No:1862 for wad/pump antiie Ruiea ar►d Ragulativns of the Siui' oaQuiri.
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<br /> Local Heatth District.
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<br /> Job Address i� ° Lot Sixe `'` PM
<br /> Owners Name `m Address Phone
<br /> _ 'C'onhactoi'30�G � p �WdrAss � '"��Lict�nsallo:;.f,!'t��Phone-� `
<br /> TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑, DESTRUCTION ❑
<br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑
<br /> DISTANCE TO NEAREST:"SEPTIC TANK SEWER LINES "- "" DISPOSAL FLO. PROP. LINE
<br /> FOUNDATION. AGRICULTURE WELL OTHER WELL. ., QITS/,SUMPS,_
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS`'
<br /> ❑ Industrial -❑ Open Bottom ❑ Manteca Dia. of We Excavation Dia. of Well Casing
<br /> ` ❑ Domestic/Private -' IKGravel Pack ❑ Tracy Type of; d Specifications
<br /> i"1 Public ARgMr n Other n Dalte -Depth of G t Seal 3; Type of-Grout t
<br /> 1 1 Irrigation Nl f( ' rgpprox. Depth I I Eastern -•Surface Se3l Installed by:!kdi r t _
<br /> Repair Work Done- 0 Type of Pump H.P. State Work Done
<br /> rb »-Wep Destntc*M_-' ryCl Wed Oiamater t.�Sealurg Materal Itop
<br /> s��. �� �" �;�t��,;;s�c�� �:��: Depe!►" ,rc�'��,�;��,-.� ,�,, s�.��i Fdlari Material'1 Batdw 50`F�: :.�'� �'��:.,. ,y� `�-.✓.#,T '�;.,¢..
<br /> }-w'-* TYPE Of SEPTIC�WORK t7NEW 1NSTALLAT1ON44- REPAIR/ADOPTION i l5 ESTRUCTION I I.INo sepsis systam permitted f pubk sewer is
<br /> �y� { t evatlsbls within 20 feet I,
<br /> 144' x?'-T '..,skr.,xi.� mi .�.ya x *-f--
<br /> Number��b4droa - ,w ra ah..E,.t '� �"-Fi.'✓,...++('�..4"G, „.aa �''G. w
<br /> J t td i 99ptlt D
<br /> `--�++�'e�+s. 4++^ ,fit • ,w �, ` E.=; #•„*y'- # _ ,^ C t�, h - -
<br /> pp�� ` F _ �•
<br /> o-- .<.1 si-'-w.f�''x Yµ "yy s *a ,s .+ Digtant;st0 nearest: ,`W 1 Feun a ;'Property Rides s -; - 1
<br /> LEACHING UNE',, ❑ No 1!, of tkrss Total
<br /> FILTER BEDr ,.'L. 'y Q- -LO.freafeeY , 'Wed iEounda
<br /> i.s u.�'c,}t•�,v�'�sw,`� Cb�+N„...�i,�� ?h�; l�d..t} � �� ;..�_{.wu'.o- ��s-'�-f <,.✓.�' ,�s�:'d„ �,i.. c_�,.n}.k.,,:-.. _ < •r- �,. J'S.�.N. }�;-,�
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<br /> �r '* SEEPAGE P f 1 Depth ' ! Site }, Numfier
<br /> ' t SUM ��►i�4{sf [k Wstance in nearest Well Founds ier► Property Line r, §
<br /> r iT 1 tht+t hfjl►e Prepared this application and that thrl vrork will 6s in accordance with San Joaquiet County stets. and
<br /> A.1x 'rules at '►egrtstlxts atm$srtJoain Lxal Health District�Y
<br /> r Hd teru lkas>r r gtt's eigrlatura cettifless fits f4tlowir►g •'I t5ertif�.Chas irs perforinartce of the,Work fw wtdeh t w'*twill, .Jr,iltAlt rtpt �
<br /> i rG l aipplulr fserw'M In Um manner as to become iub to workman's_npensa laws of Califorraa"Coirbacto►'s hiring or subcontracting aipnat�lre
<br /> '� ''1 certify that in Cite ps�torrrtattr�e of the work for ilrhich this is issued,1040 emp*partww wb w to waikman'i� `
<br /> � •a , 2R.. � i X•1� 4�` y [ �� � - F � r .7.^Yt�.d �b� ,�. �Jt
<br /> Latn to drawing On'reYeree ilde. �*» � �« E
<br /> Titls
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<br /> � i�� �_ ,�'i 7,ry 's• r .� 7>.� s k! s r �,. q,,. ��: - l �r-, ° 7 '. 7 ��� -L}r ;� ja i^
<br /> OLP.Af1TMEAll. 8E.ONLY
<br /> ,Application 3Acn9pted:by Date
<br /> c y,Pit pr Grout Inspection 6y Date Final Inspection by Date t
<br /> Additions(Comments:
<br /> O Stk i 488 87$1' C3�Lodi 369.3821 El Manteca f>2:3 7104 ❑ racy 854
<br /> Applicant- Return an copies to: Environmental Health Permit/Services 1601 It.%H xenon Ave„ P.O. Box 2009, Stk., CA 86201
<br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO.
<br /> INFO q
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