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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 488.8751 F '� ry ihdt y�r PERMIT EXPIRES TYEAR FROM DATE ISSUED �, r a; (Complete in Triplicate) oks Application is haisbv made to the San Joaquin Local Health District for a perm*to coMnJat and/or irotali the work andhereR dautibed. f thThis e an made in compliance with San J,,s in County Ordinance No.549 for eawage or No.1862 far wen/pump and the Rubs and Reguisdons of the San J Local Health L DistrictQQ - - - t Job Address _c+O �� Ja/ /a�&/ CN Fml LGh otw.r ..r � E _ 1� a -7 _� Owner's Name J�'t' 1 IIS - Address _. Phone t �r _.`I a �- S� �1 Llcenv Nolouaa Phone 5 r " Contractor VPI L"L� Address - TYPE OF WELL/PUMp: ,NEW,WELL O. WELL REPLACEMENT 0 -„_DESTRUCTION ❑ PUMP INSTALLATION 11SYSTEM REPAIR U OTHER ..... DISTANCE TO NEAP,EST: SEPTIC TANK _ - SEWER LINES DISPOSAL FLD..__ PROP. LINE k 5 a pp�a r - .FOUNDATION AGRICULTURE WELL _ OTHER WELL PETS/SUMPS .. _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFlCA?IONS - fseeg •.* U IltduttdN: - U Open Bottom ❑Manteca ...D'u.of.Wea Exava[ian r Specifications- Danaatic/PrIvab U Greve 131 ❑Tracy 'Type of Casing 1PubOther , Ll Delta Depth of Grout Seal - '. Type of Grout 1 lk f.7 I, I'F I i liripatbnAPMOa. Depth I I Eastern Surface Seal Installed by Repair Work Done UType of Pump - H.P. - Suit Work Done V✓all DesvttcLbn 0 Web Martel 0 Beeline Material i[oo 501 .. .. . - MOWh FlBerabdal IBebw 5OI r trod it Trower. TYPE OF SEPTIC WORK: NEW INSTALLATION I1 flEPAIPJADQITION 1 RUCTION I I, aystable wit�hln 200 fait t ('W �i r-a- .. i .. Installation w,0 aerva:. Residence�mmercbl_Other Number of Lwni)unrb:-_L_- Number of bed iInnpis - W.[er blob depth Character of wit to a[bPih of 3 feeC l , Nft pachY �L No: Camps- b man SEPTIC TANK 'f"n Type/MgMethod of Disposal PKG TRFJ•a MENT PLT.4 '...: _ . , . . :. `f i Dntamx io n. snarr. �{Well S D Foundation )C "toperry Imo '- <v$'y 2 J LEACHING LINE TI;T0.S Leng[h of Total langtn/sae _ FILTER.BED 7 Distance to nastiest: Well Foundation t_Property Llm.. . . ..SEE _ _ ' 5f PAGE PITS f5 I Depth _ Sieg Number m' q - - Propem/Lim. SUMPS .b?�I,fztar:ca to nearest " Wel Foundetbn DISPOSAL PONDS _.'.❑ `._ _ '�_. _ I yd, cenifY that thave prepared this application and that the work well be done in eccadsnce with San.loequin county ardiranres state lobe.std r.{, nd reuulet--of:Ow San Joaquin local Health District. o Home owner a licensed Jg®IITs sigrutun Wines the following:"I certify that in the perfonun�o of the work for which this permit a Issued.I allot rfpL � '�. employ any p'a'wn in a .h manner as to become subject to workman's compe,isetbn faun of 4;slilamia:'ConRactota hiring a wirconnaNM ilgnature certifiesfolly irlg: -I ,nify that in the performance of the work fa which this permit b tsauetl,I.veli employ persons subject to warkmaei a parrlper,ai- don lawn o the Nomw d The apparentf aR r uked. aw.Complete drawing an Title; /1'Yf`17S1� -IAS J�_.,. 07tx: signed 0' /c.Mraewt '�rIMI i.3- E1i FOR EPARTMENT USE ONLY ` - . A v3—P7 A. Application _ ..... Date_�_Applicationspectian by n Accepted by ��C.- '',' S e� Y Date Fnat impection by -('. Qata,9—U7-T _ y�LsreE ,�e C oru•r�z�ti �v /ad Gr Additbrol amttienot: - -'❑jtk 456.6161 +7 LWI 3633621 -U Manteca 6Z6Ti°4 U Tracy 6758785 --1` •. Applicant-Retum at:copses to:En Atimmenisl Health Per nk/Sonric" 1601 E. Haze fton Ava., P.O. Box 70[9, Stk., CA='6201 4E AMOUNT DUE AMOUNT PEMIlTEO CASH BY DATE PERMIT N'}. IFED 1 00 -- w EH Mu low.ttwsl I ` E:.' y '1(.�T4ai�.L, Z��.YAb•'.�'Y�S�pll/4S]YcS.{'•„'Y� /i` .-. -_.. _ - ;..J • . .'�3 -.�ak?i,`'e��it` yii ..