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APPLICATION gFAFF PERMIT
<br /> SAN JOAQUIN1QCAL,HEALTH DISTRICT
<br /> 1601 E.:HAZELi�ON-AVE. STOCKTON, CA
<br /> i Telephone (209) 466-6781 ,,, + gra r7kf� l
<br /> PERMIT EXPIfiES,1 YAR FROM ®ATE 1SUED�i,�lL .d?i 'O i cri icy
<br /> {Cornple � rjplicate), i 4 i i#3,^,•s7 ft,�csrt,i3' C,�l r Cl� fil':t
<br /> 0iii tl R ij'�i!k�:s?� `• 1 '�'7T:3r`:'_.r:es i1 14�3!�! ,.n!t';i teJn T C T xs rUG .�
<br /> lth District for a permit to construct and/or inand he�Rtul s and�R gvlations of he SaJoaquin
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<br /> Application is hereby made to the San Joaquin Local Hea
<br /> mad$'in-coYnpliance-wih',SanJoaopin-Couilty,'Ordinance`No 549forl"e Ogeor,No:s1862#orwellJpump
<br /> Local Health Dlst'rim Fi++ {,rr 3f[�a 1 sl' 7 D1.4; )s rSnE 5 VtSS (ti s` v j ;,. a J-Iaib V : ::j flr ie€v�{,,
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<br /> r iss ul s1it�".t'�/c 16VI !f"Mu f�yi#E
<br /> (� 3� /V a.. SPMr
<br /> .C � #Cityi Lot Size t.
<br /> Job Address _ r
<br /> Phone.�� "• _.�!
<br /> Owner's Name 1G � Address MI Ct+
<br /> c ,rte � �A
<br /> {r � �3S5 J Phone',
<br /> Contracto'r's Name ' 1� L+tense No. . _ .
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<br /> i TYPE OFWELL/PUMP: . J NEW WELL ❑ ' WELL REPLACEMENT G tDESTRUCTION L❑� I "iv r S
<br /> " SYSTEM-REPAIRw� x
<br /> F OTHERfl
<br /> _._..__
<br /> Ptj 1NST7�CLATION-❑ -- DISPOSAL FLD. PROPAINE=
<br /> DISTANCE.TO NEAREST:.,SEPTIC TANK SEWER_LINES
<br /> s FOUNDATION ' AGRICULTURE WELL OTHER WELL 3 PITS/SUMPS
<br /> INTENDED USE,%
<br /> TYPEiOF WELD ;PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> Dia of.Weil Casing
<br /> - `❑ Industrial ---�- =Open-Bottom•,-, C] Manteca Dia. of Well-Excavation Specifications '
<br /> ❑ DomesticlPrivate ,_�Gravel Pack y j ❑ Tracy Type of Casintg
<br /> " De
<br /> Depth of.Grout-Sea1 ;Type of Grout'
<br /> .. ., . .l'.'�...$, .c. ,+sA. ❑Othe A l❑pelta P , •-�.��+1. I
<br /> ❑ Public .; {.... �;,, ?: ' u¢='i �i R = 30t,
<br /> l ❑ Irrigatidn w _�Approx, Depth ❑ Eastern Surface•Seal Instaged by
<br /> 4 '..s i 1 H.P.' ,. �-s. State VVorkDo e .
<br /> Re air Work Done . ❑> Type of Pump _: _
<br /> p. :.. ;.•_ - - S alis Material (top 50'), " i ...
<br /> ,..
<br /> #. Weil Destruction ; ❑ : Well Diameter 9 {
<br /> pepth fi•, ;Filler Material#Below 50')
<br /> 4m No se tic system permitted if public sewer is
<br /> - TYPE OF. f. <E T available within 200
<br /> SEPTIC WORK NEW INSTALLATION REPAIfl/ADDITION❑ .DESTRUCTION ❑ !
<br /> ' lnstsllation will serve: R idence _ Commero+aY Other �3 ` , 1�1_ c�V�f IJ . ...���" `. f/, 7T
<br /> i k i. J•`
<br /> . `
<br /> d Number of living �tNumber of bedrooms+
<br /> t r� �j�lr .�... I'sV Water'tab4e depth ..
<br /> +Character of soil to a-depth of,3,}feet:` ` 1
<br /> { 1 L� a' Capacity Not Compartments s
<br /> SEPTIC TAMC _.; .j�' T pelMf
<br /> Y _9 .. _ .... . ' r
<br /> Method of Disaosal
<br /> TREATMENTI.PLT ❑ t (�+•---✓ -
<br /> '" ' Foundation ' Property Line' s2CLr
<br /> ."1 =.Distance to rierest}' Wel1t
<br /> . ,_ U `. Total length/size i`
<br /> j LEACHING_LI IENo & Length of lines
<br /> f_.____ j ItKProperty Lme
<br /> FCC i t
<br /> t ER 13ED�` ❑ Distance tonearest• Well Foundation i 1 `
<br /> �x � r �
<br /> ,
<br /> I } Size
<br /> SEEPAGI PITS ❑ Depth --Found " u
<br /> { Number
<br /> W. —� ationf a.. . w.. :^Property Line
<br /> ' i SUMPS ' _" ❑"Distance to nearest:` Well, ^
<br /> DISPOSAL PONDS_. _ ��
<br /> E' I hereby certify that,I have prepared this application and that tFie work will he'done in accordance with`Sacs Joaquin county ordinances state laws and
<br /> rules and regulations-of-the-San.-Joaquin Local Health..District..--'— t ; e
<br /> Home owner or licensed.agent's signature ceitifies the olloviring: "I ceit•+fy that in the:performance of the work for which this permit is issued, V shall'not
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<br /> employ any person in•such-manner,as-to'-become subjedt to-workman's'compensatiornlaws of-California:"-Contractods hiring or sub contracting signature.
<br /> certifies the following:"I,certify that in the performance;of the work for which this�perrnit is is1sued 1-shill employ�persons subject to w-�orkman's,compensa
<br /> •---tionlaws;of-California." I
<br /> Thea lican m call f r all,r ed +. Pe ions. Complete draw+ng on reverse side . _ •_�i _ .i. may.
<br /> �... ....,.._-a... __.� .s i. �A
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<br /> Title
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<br /> • Signed � ..._ ... _ a ._.t -
<br /> . � Dae
<br /> ME USE LY � i
<br /> l FOR DEP € l D .
<br /> _m K.- ;- ti,# �' .: ..._ Date A ea '
<br /> i ;Application Accepted by _ �- 4.....
<br /> �' n br ,,z'✓ l *. Date i l Final Inspection b Date
<br /> Pit or Grout lrispe Y t c.--- -•- ,_ -..�_.
<br /> Additional Comments: _;-
<br /> {❑ 5tk 468 6761 -' .C7'Lodi 359-3&21- p Mantec8 823 7104---t--[D,-Tracy835-M
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<br /> Applicant Return all copies to: Environmental health ftrmit/Services 1601 E. Hazelton Ave P.O ABox 2009 Stk.,! CA 5201_ _
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<br /> 9 w �---` RECEIVED BY I DATES µ PERMIT`NO
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<br /> r'FEE?� I AMOUNT D�t1 .j AMOUNT RDVIITTED r ;�C$}I �"
<br /> INFO _ i .-
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<br /> + EH 1324 IAEV.10/91 !! l
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