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J ut).till i caa ...4,M..........2...C.--- 4...-la • r A -.J./5...w a . % 0-41--- • <br />N.A./74/21.1aLsiSali.:7241.116e_Acidress Owner's Name ..'"elellE. <br />CoritraCtor •,'--.4-1-. -1!..„_;.11 Address 5.??..e2.11_tir4aW__ LicehSe NdAz5•04%14,5_ Pb."'neoleit:&5er77 <br />TYPE OF WELL/PUMP: NEW WELL 0 ' WELL REPLACEMENT "" DESTRUCTION '0 <br />___________ __ <br />T PUMP INSTALLATION Li SYSTEM REPAIR C OTHER 0 <br />DISTANCE TO ,NEAREST: SEPTIC TANK SEWER LINES _Li__ DISPOSAL FLD PROP. LINE <br />______ „ ,, <br />0 FOUNDATION _ ._____ AGRICULTURE WELL. OTHER WELL . _ PITS/SUMPS _ <br />INTENDED USE USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , _ <br />C, Industrial .ri, 0 Open Bottom IT: Manteca Oia- of Weil Excavation Die, of Well Casing <br />4 <br />0 Domestic/Private L. Gravel Pack: 0 Tracy Type of Casing Specifications . <br />i <br />i'l Public It: ii Other 0 Delta Depth of Grout Seal Type of Grout <br />I ; ltr,cjaiiuri Approk.,Depth I I Eastern Surface Seal Installed by —. <br />Repair Work Done ii Type of Pump' H.P. State Work Done <br />0 <br />Well Destruction C Well Diameter.-1, Sealing Material (top 50'1 <br />ti <br />11 Depth Filler Material laclow 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ll REPAIR tADDITIOINX DESTRUCTION i No septic system permitted if public sewer is <br />„ I available vvithin 200 feet.; <br />installation will serve: Residence. Commercial Other _I ... <br />Number of Irving units: Number or bedrooms ,,, ...._ <br />Character of 'soil to a depth of 3 feet: 1 Water table depth <br />SEPTIC TANO Li Type/Mfg 1 Capacity No. Compartments .r.. <br />PKG. TREATMENT PLT.'0 <br /> <br /> Method of Disposal . <br />I Distance to nearest: Well Foundation Property Line <br />I .L' <br />. i <br />LEACHING LINE 0 No. 8 Length of lines Total length/size <br />FILTER BED 0 Distance to nearest: Well F,oundation Property Line ._ <br />I _ <br />SEEPAGE PITS $,,Depth • —0" Number __E---05— _Size <br />SUMPS R Li Distance to nearest: Well Foundation .1 . I Property Line /€11 _ ..,242:2!. <br />DISPOSAL PONDS --) <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone t209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />(Complete in Triplicate) <br />Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, This application ia <br />in compliance with San Jcaquin County Ordinance No, 549 for sewage or No, 1862 for well/pump and the Rules and Regulations of the San Joaquin <br />I Health District, <br />i28 PM <br />hereby certify' that I have prepared this application and that the work will be cl <br />rules and regulations of the San Joaquin Local Health Datrict, <br />Home owner or licensed agent's signature certifies the following: "I certify th <br />employ any person in such manner is to become subject to workman's compen <br />certifies the following: "I certify that in the performance of the work for which t'n' <br />bon laws of California." <br />".4 The applicant-must call for all required in <br />accordance with San Joaquin county ordinances, state , ano <br />of the work for which this permft hall not .%;.. <br />orals." Contractor's hiring or sub-contracting signature <br />shall employ persons subject to workman's comperisa- .± <br />Complet drawing on reverse side. <br />Signed <br />}.zaiLieg <br />Title: <br />FOI DEPARTMENT USE ONLY <br />Date: <br />Application 'A,Ccepted by <br />Grout inspection <br />Additional Comments: <br />i7.3 .Stk 466781 C Lodi 369,3621. 0 Manteca 823-7104 171 Tracy 835-6385 <br />Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br />III <br />Area / <br />Date Date \--I c1(f3 "‘ Final Ins <br />EH 13-24 1REV. <br />EH 14-28 <br />FEE I <br />INFO AMOUNT DUE AMOUNT REMITTED Cg it <br />CASH RECEIVED BY DATE PERMIT NO <br />`7 0 - 0.14.. . i 0 -I - 1 1 ,f•-.14,0e