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APDL XAT2ON FOR PERM? <br /> SAN Cum lk _=CAL HEALTH DISTRICT <br /> tW E. t-LA ETON AVE., STOCKTON, CA <br /> Telephone (209) 486-6^81 <br /> PERMT EXPIRES t YEAR FROM DATE aSSIiED <br /> Complete in Triplicate) <br /> Appkcation is hsroby trade to the San Joaquin Local Health District for a permit to construct andlar install the work herein described. This application is <br /> L in ��with San Joaquin County Ordinance No.549 for sewage or No. !Ilm for well/pump anc me Ruies and Regulations of the Gan Joaquin <br /> Jab Address i • Kt Pb .L� <br /> �A M Lot Site 3 PM <br /> (-)sonar's Name At? T Al A'U�ei ' Address <br /> Phone <br /> i <br /> Contractor's Name • /(/uC' License No, 275 S `IJ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> hr PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE -,PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ bdtriw ❑ Open Bottom ❑ Manteca Dia. of Wag Excavation Dia. of Well :;acing <br /> ElDorrlpbcr Private ❑ Gravel Peek ❑ Tracy Type of Casing Specifications <br /> ❑ Pubic ❑ Other ❑ Dena Depth of Grout Seal Type of Grout <br /> ❑ irrigation --Approx. Depth ❑ Eastem Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> WON Demotion ❑ Well Diameter Sealing Material (top 601) <br /> Depth Filler Material tBelow 50 i <br /> TYPE OF SEPTIC WORK: NEW NJSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted K public sewer a <br /> inetalktion wig serve: RaeMence`Canmercial— that available within 200 feet.i <br /> Number of Living units:tI - Number,of bedrooms 3 _ <br /> Character of coil to s depth of 3 teat: - &A e 473 /EBr <br /> SEPTIC TANK Wat@r table depth <br /> x Type/Mfg �;�-(✓ Capacity No. --omperrnen!s <br /> PKG. TREATMENT PLT. ❑ <br /> Method ofpDiaposai <br /> Distance to nearest: Well ./dYJ foundation Property ;Line <br /> LEACHING LINE - t <br /> �I Nc, $ Length a:Imes FT Total length/size <br /> FILTER BED Distance tc :Meares¢: Well Faundatior. Praperty Line <br /> SEEPAGE PITS ❑ Depth 6�T Size ��('b' Number 3 c <br /> SUMPS i Distance m nearest: W0�.�pr .=cundation -16-f7 P.ropertv Line 3 � <br /> DISPOSAL PONDS ❑ <br /> 1 henry Cdtify that i hm prepares his spolication ane that the work will 5e cone In accordance with San Joaquin cou <br /> oaq ray,ordinances, state taws, and <br /> ntles and regulations of the San Joadutn LOCal Healfi Distract. <br /> `lone owner K iimn"d agart's signature certifies the takowing: "" cerdry Ina- :r.!tie performance of the work for which this permit is issued, I shag cwt <br /> empio� em;person n such manner as tc become subject to workman's compensation taws or t;aiffemia."Contractor`s hiring or subs ntracfing signature <br /> certifies the topowinp. .. cenity that r,-he performance at the work for which-nis permit Is issued, l shaii employ pereons subject to workman's eompensa- <br /> bGn aws Ct alNamia." <br /> ne appficanr must cal; for i napec4ions. Complete drawing on reverse side <br /> I <br /> Signec �A. ;l yTR� � Title: .✓l'...�.� Date: <br /> FOR DEPARTMENT USE ONLY 7.� <br /> Application Accepted by '7.r [) C+ <br /> Date /� �- Area <br /> Ph t i: <br /> or .irounspsction rn Date Rnal :mspeceor. by "xg4-' - Data <br /> Addhionai C.0 mlents: <br /> ❑ Stk 486478; ❑ Lodi 369-3621 ❑ Manteca 32;s-7304 ❑ Tracy 835-M <br /> Appicant- Return ah :opm !o* environmental Health Permit/Services ISM Husnon Ave., Y.O. Sox 2009, Stk., CA 9=1 <br /> ` NFC r AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED aY I DATE PEgMIT N0. <br /> EM 1}N IREv. 10/631) 1yt <br /> EH Iii ` ! iC- Go I YAW, 2k Gla t <br />