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APPLICATION hFQ�.PERMIT J yu 0 y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 . PERMIT EXPIRES 1 YEAR-FROM DATEISSUED atr,: -::aCvrnpletg in aplicate) a-s Application is hereby made to the San Joaquin Local Health District for a Permit to construct end/or install the work herein described.This application is made in compliance with SannJJwuin County Ordinance No.699 for sewage or No.1862 for well/Pump and the Rules and Regulations of the San Joaquin local Health Dis�uict. AMP 'nl +�M'PiK7fTi2Rer �• Lot size PM Job Address `/ K ,- / :206 Owners Nema �9 A'k/'Ag{deR �W Atldress ��6t�0.:1'EW Ra�. W Ay _ Phone 7� 00�/ RN Ss if,( '`I YV T�MS'Liransa No. % lig 8/ Phone Co tracto a ams TYPE OF WELL/PUMP: NEW WEL'. - WELL REPLACEMENT DESTRUCTION 13 PUMP INSTALLA��TfII,O,,,N� ....tt,� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO_ NEAREST;SEPTIC?ANK_1;t�_,SEWER LINES,,. _ ,.DISPOSAL FLO ,_�_?ROP��IINE - �• y FOUNDATION 4GRICULTU0E WELL OTHER WELL PITS/SUMPS I— h T r /� itS 61 INTENDED USE TYPE OF WELL PR08LEM AR 4� ONSTRUCFION SPE`CIFlCATION J)`" 1. Z ❑Indusviel-- 4-^•L7 Open Bottom----*❑-Mentece ^la.-of.Wea.Excavatlon. ---..}Dia..ofaVatL.Casing 1I(Domestic/Private Gravel Pack , ❑Tracy Type of Casing `$PeclBwtlons ,J ❑ Public .❑Other ❑ Delta Depth of Grout Seal (type of GroutL7 (. ❑ Irrigationh �pprox. Depth ❑.Fastem Surface Seal Installed M Ct L tXI.ST♦`A/!y Repair Work Done fiFh--eType of Pump <—t s Stana worjDw Well Destnuctln ❑�V�ell Diameter Scali Mat�rla�iop_�QI? `( ,� V rii' } '1 �t Depth Filler Material(Below 601 m TYPE OF SEPTIC 1NORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION❑ (No As tic system peunmed'd public sewer is; -, M � awIeble"w In-2001M-.)' • Installeti 'll se:, R idents_ commercial n Oer y. \ fff Number of living Units:._ Number of bedrooms ,. -/4 C{�j s CherooterioY�oll-to-e-depth of 3 feat: _) '� u+`"Water table-IdePth p t \ Capacityt r'N P. Compartments ) n SEPTIC TANK ❑ Type/Mfg ft' Method of I I PKG.TREATMENT PLT.O r 'I-N sal "Distance to ne rest: Wall ( � Foundation Property Line � t r LEACHING LINE ❑ No.S Length cf lines Total length/size y~ F 1 - I h -�� - t 'r�o�]i ndetion c Property Line�YS�L" i FILTER BED ❑ Dietence tonea res}: CII k Yk. -�-- SEEPAGE PITS ❑ Depth )� + Size t,•6�� Nummberr, SUMPS ❑ Distance to tearest:^';We11 '7I Foundation__�--r!uParry Line 1 ,•{ k DISPOSAL PONDS ❑ y Y� lti V , I hereby certify that I have prepared this application and#3at thii work will be done in accordance h San Joaquin county ordinances,'stdre low+,and rules and regulations of the Sen Joaquin Local Health D4Wri: y 1`--of it i, Home owner or licensed agent's signature c become es the following:"I certify then in the performance ogS...work for which this p sub is Issu1 ,I shall not employ any person In such manner as to bacorne.subJect tis w"orkmpn's compensation taws of CallforMe';'Contractor�gkingoFeub-contracting signature certifies the following:"I certify that in the performance of'tho`-Worktfor which this per mk is Issued,1 shRtll_pmpbY persons su> workrtinn's compensa- tion laws of California." +'4 The applicall st: I(f I r ulred inspections. Complete drawing on re eras Side. Q l) Signed Title: Ob At ACTe 2 oete I t l t FOR D£PAR USE ONLY �. r APPNcatton AccepteflJbY ` I� Date Area � ({��5-Dye Pit or Grout IncpeuK1tl7Date Fijtal Inspection by P Ad net Comments: cf �Stk 98&6181 O Lodi 369.3621 ❑ Manteca 823-7104 514 8356385 Applicant-Return all copies to: Environmental Health Pamilt/Services_1601 E."Hazelton Ave.,P.O. Box 2009, Stir•.CA 95101 " • ' FEE AMOUNT DUE - AMOUNT'REMITTED CASH RECEIVED 9t' DATE PERMIT"NDt. ww orb13� --P ` +EH lase(R v.Well I O ��5� FS10 11 _W F CH Mn - 1