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FIN APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DIST '-^T 1601 E. FIAZELTON AVE„ STOCKTON, -A Telephohe 1209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -� (Complete in Triplicate) ADplleation is hereby mode to the San Josauin Lout koalth District for a permit to construct and/or install the wprk heroin described.This applica,ion Se made in comptiance with Sen Joaquin county Ordinance No.549 for sewago or No.1E162 for weirlpamo and the Ruree end Regulations of the San Jos-Quin Local Health District. L 1 i- 1 - Job Address QU �kk GSS C'~wkr c-�il`Y S,d"aGk(��Dh Lott Sire/ PM---_ C t Alk �.s,{ Cw 73N Address ?a. &1- �067 O� ]�iVl3wV.•.�V �•H- Phone�I6��I_U'-�Oti] ownsr's Name_ --F^• Contractor St4rs, g _Add,eSe�V' y 2 ""�&CA License No._11 PhoneZ�r 57,V-157 TYPE OF WELLMUMP: NEW WELL ❑ WELL REPLACEMENT Cf DESTRUCTION LE C�' PUMP INSTALLATION f) SYSTEM REPAIR E3OTUERX_<AtL- $4fLIWA ONI- DISTANCE TO NEAREST; SEPTIC TANK , SEWER LINES DISPOSAL FLD, PROP.LINE FOUNDATION ____ AGRICULTURE WELL _ OTHER WELL_ PITSISUMPS — - INTENDED USE TYPE OF WELL PROBLFMAREA CONSTRUCTION SPECIFICATIONS T41A cult. 11;iTLWGA psILy Q Inducutil ❑Open Bottom UJ Ma,iitmu Dia.of Well Excavation Dia.of Well Casing M Dommstic/Private O Growl Pack I'1 Tracy Type of Casing Specifications i•I Pubfcc El Other I I Delta Dopih of Grout Seal Type ct Grout ._ I I frdpation —Approx.Depth I t Eastorn Sudsce Smut Insretlyd by - Repair Work Done Q Type of Pump __ H.P.-., . State Worst Done_ r Well Destruction ❑ Well Dismeior Sooling Materiel(top 50') v� ) Depth Final Matvrial IBNow SO1 W OY 1TYPE OF SEPTIC WORK: NEW INSTALLATION I I JI PAIRIADDIIION 1 I DESTRUCTION I 1 (No optic systam permitted if public sever Is N avallabto within 200 feat.l Insta!lation wilt serve: Raldence— Commercial. ' Outer Number of living units:_ Number of bedrooms t. Character of coq to a depth at 3 feet: _ Water labial depth " SEPTIC TANK O Type/Mfg Capacity No.Compartments PKG.TREATMENT PLT.13 Method of Disposal Distance to naa est: Well Foundation Property Line NILEACHING LINE n No.&Length of Bites . . Tout length/slxe A- FILTER-BEP 17 Distance to rwrost: Woo �.. Foundatioh Property Lina SEEPAGE PITS I 1 Depth — .Sime Number !`rr SUMPS LI Distance to rmwast: Well Foundation Property Line DISPOSAL PONDS ❑ I hwaby certify thAt I lwve prepared this appkation and that the work will be done In accordance with Sea Joaquin county ordi%ances.stat Laws.Arlo ` rules And regulations of the San Joowtin Lccml Heafth Diktrici. Home owner Or Ixonsed agont's signature owlitle3 the forrovOng;'I outily thet in the perforrrsnee of the work for which this Permit is issued.I shad not employ any person In etreh manner as to booms ndject to workmen's compensation laws of Catrfornla."Conuacter hiring or sub-Contracting signatwe certifies the foflow ng:"t oertity that In the parfomter=of the work for which this perrn;l Is issued,I Shall employ parsons subject to workman's comperes- tion Iowa of Collforrtle.- The applicant ceI! or ulrod Inspections.Comtlete drawing on rwerso slde. Signed TWe: FOR DEPARTMENT USE ONLY Apphufbn Aroapwd by Date 2-`.3& Area Pit or Grout Inspection by Dara—Final Inspectkm by Date Additional Comments: O Stlr 4aQ.t3yM1 a Lodi 3G9.3621 O Manton 523.7104 O Tracy 83543% Applicant•Return on cooly to:Envlronrremntsl Hahh PermitlSrrvceS 1607 C•Harehon Ave., P.O. Box 21749,Sik., FEEL INFO AMOUNT DUE AMOUNT nEviri-TEo r,ECErVED NY DATi PE W o .ar+,arslnsY.t.�er z iH,ore c 7 .. r'"' :s-Lg?-, alk+ "°?ninth••!r„a�?. 3!f,$'s`'n`a!rt,E•�,7�p T ION OF TW5 DOCUMENT CANNOT BE IMPROVED� DATE Tit THEITION OF THE ORIGI,E