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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 160E E. FIAZ.LTGNJ AVF_ STOCKTON, CA Telephnne f2rj91 4£6-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete on T":)1icatof Appf➢c,1 r,-is N!j LI1y n)a4 the San Jct quin Local Health 0W,ict for a Et.r construct anr.flof.nytafl the work herein,described. this apprtcatinrl is made a,Cr mp€;Bran with r3. joartuin County Ordinance No.54'3 for saws Loc;i I+• 7e or No, si .2 fur w.JFJfr4:mn aril rhe Rues and Rrrtlu.at;ons of lite San Joaquin ��irh p;gfriCt. Job Address / �� >��•E_ Sinn ,-�G _ PM Owner's Name /' ._L ✓= _.._ Address Phone Cosrlracia; J r__ .t Address �r!Y1-`t��/ S�_ License No.-yZf ?,1 Phan. � TYPE OF WELLY UMP: W WELL - ° �WEL.L REPLArF.k.tFf�T.X DESTRUCTION 0 PIMP iNSTALLAriON i SYSTEM REPAIR C.1 OTKER D DISTANCE TO NEAREST: SEPTIC TANK �- .SEWER LINcS �'~ _ DISPOSAL FLO. �"� PNOP, LINE ff- ---'--- --�----- -.FOUNDATION r .f-- q --:-_-__ / r. _ s_-. GRIC_UL'i UPE WFLIL_�_w_ OTHER_WEI.I- PrTS/SUMPS l?!/ INTENDED USE 'TYPE OF WELL PROf11f77 AREA COh57RUCTIOfa ;iPECIFICA i Ir)NS . I Industrial _ 0 Open Bottom w i7 M:niece O;a. of Wep Eye teat;an� t I Dia. of Well Cas;+tq ,r orrleslic/Prwato L"}Graysf Park I-) Tracy 7ipe of Casrnq,_ _ ^f�C'� Spfcificatio V!PIIM;C rr�""I O/�yyther f7 Delta Depth of Grow. Sealf�� 7�0" f{ 0 out ifriga€ion e[3VApprot. Depth 1 I Las€ern Surface Siwl 1,tetalfed ky - Repair Work Done 1,7 Type of Pump ag "'P, State Work Dons�- 1 Well Destruction ❑ Well Diameter _ Sealing fdatenzl Itat Sn'I ....._._-................Dep[hw- FilleN-Matefial fflelow 56 TYPO UF.SEPtIC WORK. NEW INSTALLATION 13 REPA€_RJADDITfON I f DESTiWGTION I i fNn Sep,.�syssem r priphG "far is �) i��s 1. _ :. , �S av3;Fablg wsfhir 2fb Irvt.i J installation w;ili s9tye;% Rasidence— Commercial _ Other _- Number of living units:. Number of bedrooms' Character of Boit to a depth of 3 feet: Water tatife depth--- SEPTfC TIANK /'--'C1-. TypelMfg 1 r .-�-- t _ capacity—_ No. tom;;•a(t-+nts _ PKG, TREATMENT PLT,11 �, �r 41. Metliod of. Disposal I E1 Oistance To nparestl'j-"� Welt-^..-,.. - r-- �.�- � -..______� FourxlMinn Property Lina � LEACHfNG.I.filE —`171 ;No. R Le�lgth of f;nes - Y _. ._ Tmai longrhis;re_ FILTER OEC '� Cl 1Distance to nearestl! Well 'i _ Fcundbrion -- t f _—_ Pratwrt5+lute SEEPAGE;'PITS .Site SUMPS .CI Distance to nearest: Weil Property Line 's DISPOSAL"PONOS IT t herar�Y i 1191 I have piopanxl this application".1thal Ihe'wafk will Lou done rr.accordance with San 30aqu;n cou ty ordinances,state taws, anrJ railesHort a r regulations of the San J,naQuin Local Health llf§trict. t l Horne owner or ficenwdl aaent'a sipnatuts certifies the li=€luw;ng:"I cartity that in the periarrranca of the work for which Ibis permit Is issued,I shall not afrovotiloy rlhe p sonhewn in such mannnify that as i to become subjance t to workman's componsaiion laws of Califoenin."Contractor's hiring or sub-eontracti�slgnaturc 'Y r r,rtifios the following;"i t eftlfy that in Nta pvrfanunce of the work for whirl,this fwrrnit is i1sued,I sttail employpersons trElbjecl to workman's Compensa floe leto►.Gatifurrsia." __��, __ ._.. »._..-_ r.. _.__.__._-_.� _.- I3 The appliean u I requ r ns.Compfote drawing on revs side. ; tl S'ignad x- Title" ffi__�'�� f I i h $ FOR DEPARTMENT USE ONLY Application Accepted by f;'; I ` r y Date J tea —J I Pit or ri lnspecfian 17y 1 Date ms Final inspection by Data f f Additional Comments: 0 Stk 466.6781 ❑ Lodi 369.3621 0 Manteca 823.7104 l7 Teary 835.63E15 t Applicant-Return all Copies to: Envfronmani i Health PermitlSurv;ces 1601 E. Hatelmn Ave„ P.O. Box 2009, Sik., GA 9L201 € \ FEE AMOUNT-OJE AMOUNT REMITTED RECLIVED 9Y DATE PEAMR�Np, €NFO I AS€! FN 1}24 lfrt\'. - sN - 4 f ,