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1 �r COPY APPLICATION FOR PERMIT Gt.N JOAQUIN LOCAL HEALTH DISTRICT J i iG01 E. HAZEL T ON AVE., STOCKTON, CA ! Telephone 12031466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED { (Compiete in Triphcatel r Application is hereby made to the San Joagodn Local Health D•Euirt for a Permit to construct and/er insuill the work herein described This application is F.'., made in compliance with Sart Joaquin Cournty Ordinance Nu.519 for sewngo or No. 1862 for welPpump and the Rules and Regulations of the San Joaquin Local Hazlth_District. 71 k.; r 2 Job Address Srl C" �C-f f!'/ i3 1 t� r%C. vr1/- 1.01 Size PM r, :'.. Owner's Names �; /-r 7 `. f" �' �-� �/ z1 .-....,Ll_� _- -- Addrrss -.-_ Phone .r 1 a.t n Cantractar✓O T�' �_� Adoressl�%'%�� _ �___—License No. ---M TYPE OF WELL/PUMP: NEW WELL IJ WEU.REPLACEMENT �7 DESTRUCTION I-) R PUMP INSTALLATION [:1 SYSTEM REPAIR C i OTHER E �?t i -DISTANCE TO NEAREST: SEPTIC TA:;K _ SEWER LINES DISPOSE' FLD. PROP, LINE ^. FOUNDAilO": — AGRICULTURE WEi.t- OTHER WELL PITSISUMPS kS; S INTENDED USE TYPE OF WELL _ PROBLEM AREA CUN`:-i M;CTtON SPF.Ci FICATIDNS - `P 8' i C7 Industrial D Open Bottum G Manteca Dia. of VPii Excavation_ pia. of Welt Casing Ll Domestic/Private f-! Gravel Pack CJ Tracy Tape<, Casrng _- Specifications y1g+ f'1 Public 1-1 Other 1-1 Delta DV.;)r c.f Crnut Sea! -_ Type of Grout I I Inigrtion —Approy. Depth I I Eastern Sur:3C:. Seal lns4lod by -. Repair Work Done I-1 Type of Purnp H.P. _ State Work Done-. �L�tt i Well Destruction ❑ Well Diameter Sr"aline Materia! [top fAb - `N Depth --�-�_-y- Fii!cr Material IBolow r,0'7 TYPE OF SEPTIC WORK: NEW INSTALLAT!i]N X74 111.{'AIItiAPb1T!,�N I I DI-STRIJC!iON I I ?ND seFriC systrsm permitted if public sewer is .k availaNe within 200 feer.l ='y Installation will Se : Residence Vr e ('ommerc:a! Other t f `i Number of liaing units'-/— Numbef of be e/ems Character et soil to a depth of 3 feet: t t/ [f Water table depth - ------ SEPTIC TANK f1 f Ype/M1 C y ----�1 �� - Capacity-- j� '_. No. Compartments .— PKG. TREATMENT PLT.❑ Method of Disposal �� x1.51 yy I - �T G, Qistance to Well cll..1'.�`;?_- Fourlr;anProperly Line on_-aO -- _k.. LEACHING LINE No. & Lergth of lines v � -- Twal?enlih/size-�. a _� FILTER BED ❑ Distance to nearest Well_ Foundation__ _ Property Line S SEEPAGE PITS �. Depth — Size.__ ' —_-Number- , ` � ._-- _ SUMPS LI Distance to acarast: Wnli._, Q_ Foundation_-GQ Property Line SI DISPOSAL POI[DS L7 § I hereby certify that I have preparod,this appfication and that the work will t,q done in accordance with San Joaquin county ordinances,state laws, and I ^ " rules and fegula6ons 31 the San Joaquin Local Health District. a Sal Home owner oclicencad agent's signature certifias the following: "I certify that in the performance of ilio work for which this permit is issued, I shall noir fi. employ any pemor.in suck)manner as to become subject to v,�rkman's compensation laws of Califomia.-Contractor's hiring or sub-contracting signaturr�'ry certifies rhe fallowi ;"i certify that in the performar.:o of the work for which this permit is issund•t shall ainploy persons subject to workman's compensa- tion laws of Calif nia." 5� �£ The app!:i:an m s all for �i qquife4 in& drawing on reverse lido. vo sF Signed X l Title:' 007Lf 25 'c+�C.y-- - Date: &P( F Q DEPARTMENT U-SE O 'LY Application Accepted by �l iii.:c^ �e:--._L.,.�ry*h;i rpt. -_ Date 1: .. YJ -M1) —_ Area Pit or Grout inspection by � .J'' ;{r�. D,nn /_';.l•, f-inat Inspection by _ gate Cj Additional Comments: �'t=1: t c ,, ' y .r, 1',,/, �. ✓s_ ;� !� - /•s,, �-_l. �. ..rn .✓•r!; �� r; ❑ Stk 466-5781 ❑ Lodi 369-3621 �❑ Manteca 823-7104 C] Tracy 835-6385` - Applicant-Return e!!copi35 to: Environmenia!Health Permi!/Services 1601 E. Haralton Ave., P.O. Box 2(109. Stk., CA 95201 'S s INFO --AMOUNT DUE AJAOUNT RLMI"ED CAS°{ RECEIVER BY DATE PERMIT NO. �, • EH 11.20 EH 13-24 IREV.F,n5) •S. '�CJ --_ ! .L '1 1"/i/1 _ •7--,- -�]','�i (,~ 'iJ /J�j� t• � ti