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�• J ' 1 APPLICATION FOR PERMIT 1 ' SAN .lOAOUIN LOCAL HEALTH DISTRICT REEIVED C i I .671 E. HAZEL T ON AVE., STOCKTON. CA Te!ephone 1.20-N *15.6761 -- PERMIT EXPIRES 1 YEAR FRONT DATE ISSUE') AUG IComFlele +n Uplicatel EINVrI�RQ[yI`� ENTiS�HEALTH andler in.tal€,`.e 9+c;t.t7.•C r1�r 1��{�?�'�{;��cz:Ian is AppGcat;on is horsy made to,^v`aa jVKu:n Local Hc4n*i D;:rict for a Terri,,o CONIruct •. nsnre t: '�E lei!e.,a a pr No.::E2 tat—11'pum,and`I`a P.ul9s and ReC-u!";L:"of the..-�:ctgwn mace:n E.�rcpr.ar�ct wish San JcrCuin Caur�:t 0'-� o.. P Local Htal:h Di:ltict. Job Address City tel S':e_ 2651 S. Airpczt Way Stockton _ Fe,+_ ��--- etainbc saki Tg Co. 3226 MontgcMC-ryr Sacto, Crnaneg61/456-3553 e,�nere ei$rt At�C:E:S GAG• _. i.G,eVi11e r � 9 g6-8S8 Andersen a 631 Commerce Dr �.,ce^eer9o.5L'�455�P9G 7 CcirlracIw.13--e�ar-}a.111��—GC 1'�"tss TYPE OF WELLlPWAP: 1,1W%'IELL O WELL FEPLACEt..E14T {} CCSTRUCi10lS 4 ' PL".'.P I':5TALLLTION O SYSIE!.1 REFAIR L? OTHER LX Monitoring] DIS?ANCE TO NEAREST: SEPTIC Yi.'.:K E': 0 t CISPOSAL FLD __ PROP.LI\ �5 r c e S 4 Ea LI1;ES - •} FOL":t'ATfO'f ACFICLL7',F.E VI'M _� OTHER WELL=-1I1tl,;75icL'taFS IhTENCED USE TYFE CF WELL FFOELEI,1 AREA C0!:5TFUCTI0I4 SFEC;FiCATtOf:S 29t Dia.of Well Casing CJ Indosir4l 1: Open Eonom G Ifarteca Dia,of VA-V Ereaea;ion i ❑ Derc.CsticiPri.t:[ i Crar_i Pack L7 Tracy ��— Type of Citing �'�n 00 _ Specif;Ca:icrs Oem nt p Q FvS Sc9S T1 pe G![rayl oenCn 1.t 11 Public (7 0:1'er fl Dolor Depth 01 Grout Seal 5] �---- 'Apprcr. Dk�:t k 1 Ease n Surfale Etdl Iny:i!rtQ Cy -rngn a T— ! I hri��tian -- ' State YJcrk Dora Fepair�'Jork Done I] T,C•e aPump ,_... H,P, Cestruc:ion L. wa 9: -noer _. Sesl;ng tAaltoial IIc,571 - - — w * Monitoring De::h F:"er Vater;al tFelcw 571 TYFE OF SEPTIC PJORK, NE1'J I:ST.I_lATt�fJ I! FEFA1RrrO01710N I] OESTFUCTIOrP l I las`bit U of v,nh;n lir]feetrie0 it publ;c s¢,ar s - InslallaliLf9 t,'iil fN'a: FtEidtrct—,_,. C;r.,:ntrcial._._„ O:rcr _. h'ur„btr rd living units: Nurn!ber cf-t '*Osr•s 1'J4.!er tab:a dtplh_ Charaatr of soil to a depth cl 3 fret! SEPTIC TANK ❑ Capaci:y No.Com=arlments — FKG.IFEATA'.ENT FLT,f] r!e:had el DispeEal D s7ancE to rta'e:+: L:'et1 Foondal;on Properly Line LEACH1t:G LINE0 s:o.E Length of Imes T Total lenSth/s;:e FILTER ER EEO a D!s:tnce to rta:es❑ L'aII Foundation PropCrly LirC SEEPAGE FITS I I Depth --Si- Humber SU311.p5 Ll Ois:ance to newest: Well Foundation Proper,y Line DISPOSAL PONMS M I heres=y ren.1y that I ha.e prepared this tppI;ct:ion and that:he 9•:ork will be done in accordance 9%.;Ih San JoaCuIn caunay crCinarces,silte taws,and rules and re3u!atiana 0f the ranlcaquir,LocFl Health Oisu;ct. rti Home owner ! Gctnstf agent's s�gnauin oc&I H rhe fosforv;ng:"I cen;fy that in the performance of she work foo which this perm;I is issutd,I shall not amptcy any person in such manner as to becc:ml sutiaCl to wofLman's eompensat;on laws e!faldnrnia."ton;Tac:or's hiring or su'�corvacting signature cenifies the following:"I cen.fy;tat in the perfo mance of the"..k for which Ih;s permit is issued,I shall employ MWns subject to wmlman's torn,ensa- ! lion 11g%5 0f C-aL(0rnla." The applicant musl coq?�1a'.red' spec+ions.Complete drawing on oeverso side, Signed X� , -- Titre:�,,a 0�!_L Date: i9° FOR DEPARTrAENT USE ONLY l Application Accepted by Otte Itar Da:e Pis or Graul Irspecuen by _� Dare _ Final moped:ien by ' :ddilicnal Comments: J S:k 4&6.6761 O Lodi 30.3Ei1 M r«!enteta E23.7104 0 Tracy EIS 6155 Applicant_ Petutn ail copies:o: Ervirerrner.!el Heaslh Permit/Services 1x61 F.)fertlton Ave.,P 0.era MA.5:k„CA 9S.201 .. ItEFHOU•:T CL'E FYOUNT FEr,!11if0CASH uK`UN FECER1LD EY PATE FEFrl IT'r:9. H,a as