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APPLICATION. FOR.PERMIT
<br /> SAN JOAQUIN,LOCAL-,HEALTH DISTRICT
<br /> 1601 E.,HAZELTON:AVE., STO,CKTON, CA
<br /> Telephone (209) 466-6781
<br /> +ti cid! r�rj Y.•: •
<br /> PERMIT EXPIRES,1 YEAR FROM DATE ISSUED
<br /> ,d;t3f1�IC12�I{�GEJf;�SI?1E-�sJ int/1„+. � _
<br /> 3� , „i:�te€, ��r� :dlComple#e In Triplwcate}, A :s l i4 ,u,o ua
<br /> ii e
<br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein:,:descnbd-. Ttiis appliCa#ion is
<br /> made;irs:compliance with SamJaaquin County,Ordinance-'No t 549#or�sewage or No;=1862 f-or,_well/pump and;tF e'Rules!and-.Regulations.of the San.Joaquin
<br /> Local Health District,, i3
<br /> •,..�, p� x , 4. �cl) THst�,".? ","1� T•� .sit, �c t ,,f'"CI 3�."+ `��}"�:G�', Vic+ ("is�,et'?,?"t fsd'�Y,.F3 �'3s f,���j 1;,
<br /> lo,t'0i
<br /> } �';" X ' r'I4'.Iyer
<br /> 1. .SLot Size
<br /> Job Address .
<br /> 'PM.
<br /> t., ., ' y'..(` •—. .,,r,: ., .. _ �t� f t,.'•x _ .ter.., �, .�... ,_—a
<br /> Owner's Name /J- .� �. _ --;--Address Phone ..
<br /> L Cod to s Name (+' License N -- ; -
<br /> o. — — Phone,-
<br /> I TYPE OF:WELL/PUMP:' i NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTION/❑ I i
<br /> I i PUMP INSTALLATION 1VF SYSTEMREPAIR 171
<br /> _ iDISTANGE TO NEAREST: SEPTIC TANK "SEWER LINES ` j, k "DISPOSAL FLD, PROP.11NE -4
<br /> l 3 E r ?
<br /> FOUNDATION'- AGRICULTURE WELL• I OTHER WELL ` PITS/SUMPS TENDED USE U5E TYPE OF.WELL...,,. PROBLEM AREA CONSTRUCTIONS
<br /> I P,ECIFICATIONS
<br /> -- j-❑ Iridustrial D:Open.Bottom" --- ,❑ Manteca"�,, • . .`Dia: of"-Weil Excavation ;. Dia 'of-WefLCasing
<br /> Domestic/Private ❑'Gravel,Pack ❑ Tracy:;Q ;Type of Casin s I
<br /> �---•• - x. u 9 _ ___ 9 Specifications
<br /> ❑ Public i I� �p Othe �_ '❑ pelta Dep of Grout Seaf Type of Grout
<br /> L - <❑ Irrigation--I--- •• __-_Approx,.pepth © Eastern a Surface Seal Installed'byi
<br /> Repair Work Done ' D ; Type of,Purrip H.P. s # State 1Nork Done Y
<br /> Well Destruction ❑l Well Memo a Sealing Material {top 501
<br /> 1 }
<br /> p. ..FF
<br /> i e
<br /> sFillerMaterial (Below50)
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No se tics
<br /> " �.._._.,� _ , -r. p ystem permitted if public sewer,�is
<br /> _�. + -- . . ._. l r f^ T,.__. _ 1 -._.,� , ,. available'within'200 feet.)
<br /> Installation will serve: Residence _. Commercial Other
<br /> Number of living units: Number of bedrooms ,
<br /> !' Character-of Boil to a deptli of 3 feet' -t -Water table depth
<br /> 1 .. ;SEPTIC TANK 4,Type/Mfg . '° th Capacity No. Compartments
<br /> i PKG. TREATMENT:PLT!❑ ; ! j i J Y t Method of Disposal. °
<br /> i Distance to nearest' Well Foundation'� �. Pro
<br /> Line
<br /> -...� AertY �
<br /> LEACHING LINE ❑. No. & Length of lines ° ,r Total length/size
<br /> rr ;
<br /> "r FILTER BED #'-- t'0. ! ?i Distance to nearest: Well "� -Foundation r "------Property Line
<br /> .... 4 � ( I _
<br /> SUMPS r I Distance"to`nearest:' �"Well—
<br /> DISPOSAL
<br /> SEEPAGE PITS j ❑ Depth ` rSize'{
<br /> Number
<br /> +13 Well
<br /> I
<br /> _ "mak' ation,�^K-� -`��Property=Liner •�*�:-�. --- •^ate.--.
<br /> 1 DISPOSAL PONDS ❑ j ; ! ! s
<br /> I hereby certify that I have prepared this application and that the.work will be done in accordance with San Joaquin county ordinances,"state laws, and
<br /> (rules end'',regulatioris•of-the-San-Joaquin-Local•Health District: �• -�5 •; -u e: _ .}.- 1
<br /> Norfollowing:" {
<br /> Horne owner dr licensed'a agent's si nature certifies the I g 9 _ "I ceiYify that in the performance of the work for which this permit is issued, I shall not
<br /> employ any person.in"such-manner as to tiecome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature
<br /> certifies the following: "Ijcertifyill the performance of the work for which this'
<br /> permit is issued, I shall-- employ;persons subjeclo t to workman's compensa-
<br /> tion,laws-of California.!'+_
<br /> t The"applicant mus all or a � ur Inspections. inplef swing,on re
<br /> 5igriedr! y. Title:' ��� Date ..}
<br /> . ,_� _f ! f_ _ j t s + FOR DEPARTMENT USE ONLY
<br /> Application Accepted by 4� T' Area s,Q ( r
<br /> - ttDate r f _
<br /> i Pit dr Grout Ins by j Dat Fina Inspection Y ~Date
<br /> Addrtionamm
<br /> l Coents. f iT jt t ,. r t om. Hsi "�ir
<br /> --4- Stk 466-6781- -- Q L/odi 36&86'11- + ❑ Manteca -823-7104 ❑:Tracy 835.6m a
<br /> I Applicant- Return all copies to: Environmental Health Oermit/Se'rvices 1601 E. Hazelton Ave. P.O.Box 2009,6 Stk., CA 95201 2 r f
<br /> - --
<br /> _
<br /> FEE
<br /> ` iii �INFO _ s? ! -1 4jCKAMOUNT DUE MREMITTED GASH RECEIVEU�BY+_ D
<br /> ATE
<br /> + W PERMIT ND.
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<br /> 1
<br /> EH 13-24 TREY.101831
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