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APPLICATION FOR PERMIT 3 r SAN JOAaUIN LOCAL HEALTH DISTRICT r y` 1601 E. HAZELTON AVE.. STOCKTON, CA Y Telephone (209)466 y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iCompleW in Triplicate). . r:,^ �:'^tl S' - Appikation Is hereby mode to the San Joaquin Local Health District for a permit to cotatruct and;a Install the work heeeln tlwcrlbed.THIi ipplleal7pn t• made In cornplience with San Joaquin County Ordinance No.649 for sewage or No.1882 for wea1purnp and the Rubs and Reyulatione of the Sat Joaquin Local Health Dlatrict. I u Job Adthsa City J .Lot Stas Q Ph_A `� Owner's Name Address ,A� 9L Contractors Ni+me rl icenae Na. to l 0 7-Z PhaM TYPE OF WELL/PUMP: NEW`NELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ = �`PUMP7NSTALL'AMON'Cl- --------SYSTET.A-REPAM-O'— OrrfER 0 +'`�a'v thG DISTANCE TO R'"`.REST: SEPTIC TANK 131SPOSAL-FLD. PROP. ;"-r, i FOUNDATIOfV AGRICULTURE WELL OTHER WELL PITS/SUMPS 'T 4 �•' .<INTENDED USE T:PE OF WELC.- PROBLEM ARFA CONSTRUCTION SPECIFICATIONS }I c ,Q Industrial : ❑Open Bottom- ❑Manteca Dim.of Well Ehcavetlon+ Dl .at Will Cashtg " 0 Dotrvn8c/Private i ❑G►evel Pant ❑Tracy Type of Casing SpaeNleatiana �' +^ ❑PuWk . ❑Other , �' 10 Delta I Depth of Grout Seal l Type of Grout z + O.Irrlgatlon i '_/lpprox.Depth' . Ct Eostemi Surface Seel)mailed by_ t �Repair Work Done ❑ ; Type of Pump �� - H.P. State Work Done_ ! Walf Destruetim ❑ Wail Dlameter Sealing Material(top 60') Depr, �ti {;,�IlerMaterwIBelow60'1 '' .f....,��..�� , rt ,LTYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIRTADDITION -OESTRUCTlON-G3-INo septic tw,etam K Public sawn is,,,• i "!'I 21310t/!t 1 _ � a, f ztrmstatleelon will serve: R Commercial Other 'y Number.*}11mmp unlb:INUmba�Of ` m+ Chmracar.of$a to a depth of 3.feet: � '' Water able depth SEPTIC TANK .Type/Mf4_ CaAacitY No.Camparptrna w r'^'twr a *fit, �F vM PKG TREATMENT PLT.-b 1, -^ �� :�_ Method of phpoaal l Distance tc naer4t '.'Well'. FoundationProperty Line -'t' :s. �� 1T .>�•;R� ink ��,r 'f••LEACHING'LINE I No.6 Length of lines' %=- Tout length/ FILTER BED O Distance t0 riearestc"r s lil/eN' ._.Foundation Property Line Y Y .:SEEPAGE PITS' d Depth Sim V her „ ' �" ti`` :' '• SUMPS Distance to nearest: Well Faunderion — f4opatty Lite.ti y :DISPOSAL PONDS Q I • i.;z i�+ ,�l ;z .;� I;. +-Yr<. j, 1 hereby cerft that 1 have prepared this applioatlon and that the;;rk will be done in accordance with San Joaquin county onttrt mom u tta Nwa,and�� u jet--" :rubs and regulmdons of the San Joaquin Local Health District. Homeowner or 0oensed agent's signsture certifies the following:"I certify that in the perfommena or the wr rlt for which rete.pirmlt w laatrad�l ehaM rtut - ' el :,anpby any parson In such mend thas to become subject eo workman's conmperwdon to as ad Captomia"Corttrectora h4Mrg a aubeontrrctMtp tlipMatf/n } certifbs e folowft:"1 certify that In the perfomtathe nce of- work for which this pemmlt In kstud,I ahall employ persona subject to wtrirrroWs ootrpanatr t; r ftn laws Of California."' :_ Jil :{ r, J�f• . ` Tapp8cent, ust call for all required l4pections Complete drawing un rovereeThe X-.� �, - Title:S Date `� ,• ' FOR DEPARTMENT USE OF ^-- :c�'S.' aFI4� ;i .-Application Accepted tsy' _ _ Doti ;ir' �' "At"; �•7 r/ } g��, "+ Pit or Grout Inspection by a Date' „ yT -T'Final Inspection by� t Dtapa - `Atkillronil commena; Q Sok•4466.6781 O Lodi 3893621 CYMa13 Tracy 836-0366 - °�• z+ �{ tr L Applkant-Return all copbs to:ErWnx rnentai Health Permit/Savices 1601 E.Hazelton Ave.,P.O.Box XIM,Stk.,CA 66201 y INFO AMOUNT DUE_._ AMOUNT AVAITTED... AMNO6Y _ _GATE i ..-_ CASH -lEIIMfYNO ,-�4 _ tt JAN• 1={ y.q p ....�_,',_..�... � ' S i