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t <br /> I� <br /> APPI 10A11(IN I flit I'Ef1MiT <br /> • 1*AN JOAtWIN LOCAL MALTH DISTRICT <br /> 1tkil k i fAZELTON AVE. , S 1 OCK10N CA <br /> 7"10010110 (4-091 466 b1fil <br /> PISAMIT E_xpl1`1993 i YEAR_FAOM DATE ISSUCO <br /> 4 I Cclmplum In 10piwei 1 . <br /> Application Is hMaby made to the San Jnequin Local Hitailh Di61110 for a permit 191 t:on IFUCt and/or etstaft the work heism desvibedd This <br /> appitcalion <br /> rtlede M compliance with Sall Joaquin Count f Ordt'sancu No fA9 lot sewatle ur No 1667 for wail/pump and the Rules and Regulations o1 the S&A qu n <br /> Local Health District <br /> Job Address 1448 N. El Mracb Street Stockton 120' X120' <br /> City Lot Sue phi <br /> Owner's`NP—a Wlc*lw d Ch1 Cb. Address 1765 Ciaiilenge Wy, S3L—nekt>01 CA 95815 Phone X16) 921-11100 <br /> Contractor WBsteTI Geo- f xB Address 1386 E. Beater St., Woodland. 5—License90 �i 13(357 Phone (916) 662-4541 <br /> TYPE OF WELL/PUMP NEW WELL 09 WELL REPLACEMENT 0 DESTRUCTION Q <br /> PUMP INSTALLATION ❑ hySTEM REPAIR C7 OTHER d irIXkit=/%=M y <br /> DISTANCE TO NEAREST SEPTIC TANK ___,ii} 8_ SEWEZ LINES J21 DISPOSAL FID N/A PROP LINE 60` <br /> FOUNDATION —JX` AGRICULTURE WELL l OTHFR WELL � PITS/SUMP.—WA- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (3 Industr d (� Open Bottom ❑ Manteca Dia of Wen Excavation-35" Dia of Well Ca" 4" <br /> 0 Domestic/Prhra'a ❑ Gravel Pack L1 Tracy Type of Casino Specrficatioris <br /> 11 Public (-1 Other 171 Delta Depth of Grout Seal _ Type of Grout Mat _ <br /> 1 1 tnigA..ort — Approii Depth I I Eastern Sutface Seal Installed by— <br /> Repair Work Done L] Type of Pump H n State Work Oona <br /> Wall Destruction U Well Diameter Sealing Material hop 50'I <br /> Depth Fillet Material IBe4ow Sty} <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INa septic system perrttitted 0 ptrbbc twtiiier is <br /> Installation will senro Residence_ Commercial`_ Other availahle within 200 feet 1 <br /> Number of living unite Number of bedrooms <br /> Character a1 Soil to a depth of 3 feet Wavw table depth <br /> SEPTIC TANK C1 TwolMfg Capacay No Compartments <br /> PKG TREATMENT PLT f1 Method of Disposal <br /> Distance to nearest Wen fotxtdauon � Progeny Line <br /> LEAC14ING LINE Ll No &Length of(fines Total length/sue <br /> FILTER BED 1.1 Distance to clearest Well Foundawn Property Lina <br /> SEEFAGE PITS I I Depth $Ira _ Numbot _ <br /> SUMPS L I Distance to nearest Well Foundation ` Property Line <br /> DISPOSAL PCNDS <br /> I hereby certify that 1 have prepared this appimation and that the work will be Ilona in accordance with San Joaquin county ordinances state tows gntl <br /> rules and rogulalrons of the San Joaquin Local Health District <br /> Monte owner or licensed agent a signature certifies the following I certify that In the Performance Of the work for which then permit is Issued I shalt not <br /> employ any Person in such nwarlar as to become subject to workman s compensation laws or C&htorma Contractor's hirx►tt orsub oontractatg Californiaure <br /> certifies the following I cenEfy that in the performance of the work for which this permit is.slued I shall employ persons subtest to workman s corrrpignal <br /> tion laws of Californ <br /> The applicant mus for r Complete drawing on reverse side <br /> Signed Title .,B= kt (C-57 #513857) Date 10/25/B9 <br /> FOR DEPARTMENT USE ONLY <br /> Applicati Accepsad by _ Date Arca <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments <br /> ' O Slk 466 678' O Lodi 369 3621 L7 Manteca 823 7104 n Tracy 835-6395 <br /> Applicant- Retum all copies to Environmental Health Permit/Services 1601 E Nazalton Ave P 0 Box 2009 Sik CA 95201 <br /> • Et I AMOUNT DUE AMOUNT REMITTED CASK RECEIVED r]Y DATE <br /> INFO PERMIT NO <br /> . EN 13Y`AEV 11Kei <br />