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09/20/2004 10:18 464013EENVIRONMENTAL HfH PAGE 10 ARPLICATI014 FOR PERMIT, , r 7 SAN'JOAQUIN LOCAL HEALTH DISTRICT 1601.E.'HAZ,ELTON''A�€'•, STOCKTON. CA Telephone 12091 466-6781 _PERMIT EXPIRES 1 YEAR FPOM DATE ISS lComplete in Triplicatel Ilcstion is Health permit to cnnsirucl andfor install and In,work ilis Ru es end IR positions of cilbedis SM Joaquin Application is heliby made to the Seo J06qu1 QLocal (conq No.549rtnr s wag or No. 1662101 wP.11/D ump made 1n comollen40 with.San Joaquin County - Local Health District' a _,.Q City mac .°-- "-- Lot Size Job Address -� • — w , ! Phone Address"��J't?.v1�_ - ---�'�� Owner's Namee� y,i...:../ (. . .•r .� v 7 ,t. A 1 5 rt-) . a q E1�l�License No. y �r phone_,e._.—• Address JCL-Lf• •e+ Contractor WELL REPLACEMENT C1 DESTRUCTION TYPE OF.WELL/PUMP: 'NEW WELL IJ OTHER C7 SYSTEM REPAIR 17 J PROP, UNE PUMP INSTALLATION SEWER LINES _ DISPOSAL PLO.^— DISTANGE TO NEAREST: SEPTIC TANK. OTHER WELL PITSIS_UMPS �� t FOUNDATION=_ AGRICULTURE WELL , _ _ f INTENIJED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF_!CA710NS Die. of Well Casing _ pia.of Well EFcaVatlOrt Spaeifications C7 industrial Cl Open Bottom .l� Manteca . L";l.7rdcv'. : Type of Casing— ----�� Type of Grou+fj✓r-11.+'��'w . L.I Domestic/Private f.1.Gravel Pack' Depth of G,614 Seal, --�� • ........ I;1 Other., ::. .. .,..n.Oelta.. '.: I'1 Pllbtk•l S.Aaeu SYJI Installed by —rt�'�- -•.,Approx. Depth 1 1 Eastern ----- 1 I le ipxtio^ H.P. --..—_�_..._...._..—.- State Work Dnne Renals work Done Ll Typo nl Pomp _.----- Well Oismeler kdcaling Maledal (lop 50'1 , well Deaguctio^ Filler Material (Below 50'1 Depth.:_-S�^ lec+.l available within 200 TYPE OF SEPTIC.WOR K': NEW INSTALLATION I I REPAIRIADDITION i DESTRUCTION 111No septic system permitlud it public sower rs Installation will serve: Residence commercial.__"Other Number of living units: Number of bedroOM5 Water table depth Chars lot of Soil to a Depth of 3 106U �1 Capaclty� — No. Componmems 'LI Type/Mfg _. '�' Method of disposal SEPTIC TANK .. .. . ' FKG. TREATMENT PLT.f*0 Foundation property Lind i Dislaboe to neor6st:;' Well J�f ��_ Total length/size �—' LEACHING LINE' Ll No. 8 Length of lines Property Line FILTER BED Ll Dislaneato nearest: Well Foundation�— Numoor I I Ut10+h r`Size —f r Properly Linc SEEPAGE PITS »Foundation SUMPS CI Distance to neatest: well ,. 1 DISPOSAL PONDS fa urn ceuMY Ordinances, state laws. anti I hereoy certify,het I have prepared this application and that the work will De tlone in,accordance with San work to Permit is issued, 1 shall not rules and regulations it,lns San Joaquin-Localcrti Renal D lowing Home owner of licensed a ant's signature lliHe alta DAIti in 'I cadlly that in this pedormence of the work for which this certillsa the tOlbwin "I candy Ior in the come subject of the work for which this permit is issued,I'shall employ persons[object to workman's compenca- employ any Dors°^in eueh manner as to tiecome auDjea to workmates compensation laws of California. Gomraaor's s sub Or iso workman's C MPer ore ance g, ., tion laws of Caldoinie. `The Bootie call. t all/jag4irad incpscalona. ColtiDlete tltev6ng o�evarce side.., Date: Tide; Signed -- Tfop, DEPART E T SE ONLY �r. rte/ Date ,7Y ri; i/' ale Application Accepted by �,: action by .dateFinBIIJRo1p ' Pit or Grout Inspection byFf- '•'` r. ""❑ Tracy 1135-6305 . 0 Sik rel -97111 tel: Man 823-7100 5u afA-fl7111 ❑ Lodi 369-3821 �( P P.O. Boa 2000. Stk., CA 95281 Applicant.• Retum ell[.plea to: Envuoninentai Health Permil/Services IGot E. Halohon Ave•. AMOUNY REMITTED ABH/ RECEIVED 6Y GATE PERMIT'NO. FEE AMOUNT DUE INFO �% ^'t .•t,.�L)E . Fh U•N IaaV,vxel - li 14 x ._�