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_ 4i•*e 4�':M W7rA Q C M d '� • �'�. r �iTy.ra4yf4Mi4, it s APPLICATION FOR PERMIT n - tE - .a _ .. •vii' �. SAN,JOA QUIN tUCAI HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA >' QJ Telephone (209) 41,%-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S (Complete in Triplicate) ' n Is hereb made to the San Jogpuin Local.Health District for 8 permit to construct and/or install the work herein described.This applieetiot. �,.. Appllmdo Y _ made in compliance with San Joaquin.County Ordinance No.S19 For sewage or No.186 for well and the Rules and aeguletbna at L'te San Joaquin Local Hem"District ' •y w i _� N �n City of Size PM , ti t" i-Job"Address dr � /�- C,.WC ll( L] Phone y� ��Owner's Name dress . # �7t / — Phone . 4 License Na. Convectors Name + = NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �b .-IYPE OF WELL/PUMP: OTHER ❑ 4`.r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ PROP. LINE J7f DISTANCE TO NEAREST: SEPTIC TANK �LY�.� SEWER LINES '�/�� 1 DISPOSAL FLD._ I AGRICULTURE WELL OTHER WELL PITS/SUMPS 1NTI N��ED tJg6' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing fk «; krldustrielx� ' �F❑Open•Bottom ❑Manteca Dia.of Well Excavates` r` d �- T of Casio Speci ications 611 tom,L},Do rrtre+stie/Private ak , �ifavBl Pack' ❑Tracy Type g �� / Type of Grori t�f a 0(fther ❑Delta Depth of Grout Seal _ Vl tw. . ❑',Publk tt t Q a`w *S❑ Irri trop y £ �,tiK -�Approx. Depth ❑ Eastern SurFace Seal installed by , �' H p State Work Done t ' He it Wi�rk;none ❑ TypA of Pump 3 ❑ WeII,Diameter Sealing Materiel!top 50') 1 Well Destructions 'r rn Filler Materiae{Below 50') ,v. u r 1 T'PE 0`F�SEPI C WORK: NEW INSTALLATION❑ REPAIR/ADDi ON ❑ DESTRUCTION!❑ av0 septiclable sy�itte2DD leatltted if public sewer ns r is 1lnstatlatian will serve .Residence"_, Commercial_ Other 11 :Namber of living units: Numberof bedrooms Water table depth �`Q} ;� Cherecter of soil to 8.dePth of 3 feet: �tNo. Compartments si SEFnC TANK "".°" j❑ Type/Mfg Capacity Method of Dispose: w PKG TREATMENT PLT ❑ r w Foundation Property Line A t.Distance to nearest: Wali v J V J i LE4CHING.LINE, Sz ❑ .No.-&Length'of lines Tota!length/size �5 d Foundation Propdrty Line ±, FILT�R,BED ❑ "Distance to nearest: Well 1 i Number 1 ; 1E.PIT + ©k Depth Size n Foundation Property Line f; SUMPS ` :K ❑ Distance to nearest: Wall_ i t k'kDISpDSAi'PONDS '��❑ L certify thet.l have prepared application and that the work will be done in accordance with San Joaquin county ordinances,stats laws and , ,P n.,i 4' lrules and regutatrorts of•the,San Juaquin.Loeal Health District. lHarne owner a,licensed aQm1t's signature eerCdtes the following:"I certify:not in the performance of the work for which this permit is Issued,I shall not c ; ring or su employ any person In such,manner as to became subject to workman's compensation laws of California." ploy pto�sisubject to workmen eb-oontraCtiscampsrlss- +s. drtities the fallov�ing: 'I certify that in the performance of the work for which this permit is issued,1 shall employ pe ,. tion laws of Califomis ; Thea ust call for all tequl nspectionb:Corp '(e drawing rn rse` �> f Tit19: f o J Date. C� ' .` Signed , 4.r FOR DEPARTMENT USE LY + a�Y YF ei,M ;n Date Area U +�ApplicationAccerptedby (� VV � � Date Finer Inspection by .Pit or Grout insKection by t J itwnaI Comnlarrta ° tlr•'.X8781;„: ❑Lodi 389-3821 ❑Mantccs 823-7104 ❑Tracy $3&8386 q ant-Retvir atl copha to: Envirarlmental Health Permit/Services 1801 E. Hezekon Ave., P.O.Box 20179, 5t1c..CA(6201 FEE AMOUNT DUE AMO REMITTED RECEIVED BY DATE PERMIT•N0. x a .'.�,i."nts: ..ionm EN 1426 *r li •,thgS:�.li!e ef(rK *� y ad'. "N.` I' .�os _.�A A',• t,« :1 V.- k •1. 'f-•