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. s r t�• APPLICATION FOR PERMIT f C Imo' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA U" Telephone (209) 466 POI PERMIT EXPIRES I YEAR FROM DATE ISSUED "` xis (Complete in TripIkAte) Application is hereLy made to the San Joaquin Local Health District for a permk to construct and/or irratall the work h,.rain Tt Y made M compliance w;th Sen Joaquin County Ordinance No.549 for sewage or No.low for welllpump and the Rules and Regulations of tfee San Joatpdte ' Local Health District. , I Job Address S 3 rn�v d city 0 Lot Sts+e.� � �G• PM Owner's Nome t ,N Address 16010 'f. rG•vd f Phorea -s� d � \t + rL�No. Ph" .�e�- 04, y Contractors Name W x TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT fl.'»' DESTRUCTION ❑ °z e PUMP INSTALL/v ON SYSTEM REPAIR 0 OTHER ❑ ; 6a . DISTANCE.-TO NEAREST: SEPTIC TANK N SEWER LINES //VV� '� * POSAL FLDE.� PROP.UNE FOUNDATION AGRICULTURE WEItQTHEi4 WELL>ru Lam.PITSISUMPS�N�'C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r r• p industrial A Open Bottom ❑ Manteca Dia.of Wen Excavation7 Die.of wen Casing 4 � Y VD ❑Gravel Pack ❑Tracy TYPO of Cas >� �E ❑ Public 13 Other ❑ Datta Depth,of Grout Seal of G ❑Irrigation oA$APPrh+x• th ❑ steers � °- Sural instaNed by I' y Repair Work Done ❑ Type of Pump � H.P. hStats Work Dana well Destruction ❑ Wen Diameter Sealing Matariei(top SWI Depth Finer Materiel(Below SO') + TYPE OF SEPTIC WORK: NEW INSTALLATION 13REPAIR/ADDITION❑ ,DESTRUC ION❑ (No septic system permitted if pubne sewer is • " evaniWe within 200 feet.l Ird allation will serve- Residence— Commercial— DOW Nuirdw of living units: Number of bedrooms a ;Ii 'Character of son to a depth of 8 feet: E Water labia depth " r � .lar ay SEPTIC TANK ❑ Twelmig PKG:TREATMENT PLT.C3 r � WOW of Dkrpoal T Distance to nearest: wen Foundation... Ptopaellr Lina $ * Tobi WMgh/ LCACHING LINE ❑ No.m Ler►gM o1 Imes r r a FILTER BED C3ea Diets noe to nrest: Well Foundation Property Lints SEEPAGE PITS ❑ Depth SIN Number SUMPS ❑ Distance to nearest: wen Foundation s PrOPertti urhe - DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordlnanwaa•am laws.and (� rules and regulations of the San Joaquin Local Health District. Noma owner or neensad agents aignswre certifies the following:"1 certify that in the owformiance of the work for which this permit is issued,I Shan not employ any person M such manner as to becoms subject to workman's compensation laws of Canforrda:"Contractors hiring or sub-contractirq signature oanKies the following:-I char"then M the perkwr►en a of the work for which this porn*is issued.)shen employ persons subject to workman's compensa- tion Won of California." The applicant must eon for all required krspecttans.Complete drawing on reverse S�X_. y �y ,�.rt.tc Tlar • vet•; `r 8 -- FOR DEPARTMENT USE ONLY ( Date s` Arae Application Accepted by p r` Pit n!(irotft Inspection by Date 0 0�� Final inspection by X---) /T DIN T 11ddltlorrsl Comrthants: E3 51k 486-MI ❑Lodi 3S0*21 ❑Manteca 823 7104 ❑Tracy Svj4m Applk ant-Return an copies to: Erwirenrnamel Health Permit/Services 1901 E.Haxehon Ave., P.Q. Box 2009.Stk.,CA 95201 FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY HATE NC MI - INFO jib-/��.3 .a�tu.tater,toratl D4 �'00 3✓�/ .Gig.. l Ka« retdyt iAr, ".4+u+tia.�f...'41LS¢�SekNrr.^Y" C rA +eA,Ft73+K,�".. `9mt;A" ,1rYd' .:.'X•: :. >. �c�, s i t t d M' _ :i 7hT 4:.�y• ?� ��'' .yr�Ml t iW_ f �__`i t, � .. _ -