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I r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F. HAZELTON AVE., STOCKTON, CA Telophone (209'. 46G 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " [Complete in Tripllrwel r install work n described. Itrr:drtin c^1mplianoe will,SonoJraqurn Cn ttry Ord nJoiquin �InH,No X4`1 District for sewall"Or,INO. 1962 Ior well/P�np ant the Rufus lan d IR Uuiations of the San Joarnrin Lora;Health Dmi,ic'. �/J� City/_VVvre_4A_.... Lot sit",Jct-Andress _(,�Gt.l t4..L2vl' - C�/IGS_. Address Owner's Nanw - Kp'44l d I ccisc No. - ----�-�- WELL REPLACFtAENT [:1 DES'Y.UCTIO" �, TYPE OF WEI LIPUMP: NEW WELL L1 OTHER C1 SYSTEM REPAIR 11 ` ' PUMP INSTALLATION 11 PROP.LINE _ DISPOSAL FID._- +. DISTANCE TO NEAREST: SEPTIC ZANY. __---- SEWER LINES ---------- OTHER WELL PITS/SUMPS -.___-.-..-- ------- FOUNDATION -. _.-AGRICULTUFE WF.LL__.^�.__.-___.-------"----_---.— IMTENDED USE -TYPE OF WELL PROBLEM AREA-CONSTRUCTION SPECIFICATIONS-- Dia.of Well Casing '- '- - - W --- ---' Om.OI Woll-Ex- -'-------" (l Manteca ' Industrial [..` Open Bottom SOecdications - � '.. ;ravel Pack C I Tracy" Type of Casing- ------ \ Domestic/Private I-I I 1 Delta Depth of Grout Seal Type or Grout - -- J L1 Other - 1'I Public - Surlato Seal Installed by- �� I 1 Irrigation -_.Approx. Depth I I Eastern ---' H.P. _ State Work Donn-.-_----------'_ 1 Vv\ Repair WOO,Don, f 7 Type of Pump _.-- _ Sealing Material(top 50'1 Well Destruction [.7 We9 Diameter _._.----- Filler Material(Below 50') ..._ Depth -- p available within 200 feet.) 1 YPE OF SEPTIC WORK. NEW Z INSTALLATION I I REPAIR/ADDITION OE`-.T1IUCTION I I INo SePuc sysh"' nnnuled it pubLc sower is 4.' Other 4 1 In5talWtion will serve:. Residence Z- Commercial-_ - Number Of living units:_,I-- Number of bedrooms_Z -Water table depth- - Character of soil I.a depth o1 3 feet: ___-�. �y No.Compartments Capacity--_---- SEPTIC TANK -1 Type/Mfg -- - - _ Method of Disposal PKG.TREATMENT PLT.1, Y w, .Property Line /^ Distance to nearest: well Foundation b►�7 —/ y ` - � -._------------" HD r Total length/size_____- A - Cl No.&Length of lines .-_ a y!- Property Line LEACHING LINE �0 rF&ndaton_ I I Distance to nearest: well_�__- FILTER BED _ ---- 4 _--__.- -----T v r—__ Number -- -- I I Depth __f 2 Sea--t°s--Z 5�} {•roPeny Line - - SEEPAGE PITS 'Nett - f2S, - Foundation_. •` I Distance to nearest: -- DISFOSAL PONDS I 1 state laws,and I r,oreby certify that I have prePemd this aPPlicaucn and that the work will be done n accordance with San Joaqu,,county ord,nances, rules and regulations of the San Joaquin Local Health Di3tncL „1 certify that in the performance of the work for which this permit a issued,I shall not ,r •)ns subject to workman's compensa- HOnie owner Or licensed agent's signature comities the following:,to employ any person in such manner as to beco'emabce of Othe work afor whiditt this permit is ssuedilI shall employ per employ hiring or sub contratling srgnahrre +• certifies the followingcertilY that m tis pe ' tion lows of Calif. a CeN -RA`�}-L�,� Jt-' �/ �- - applicant mu n1�AF-7 i1`pisoect.ons.Complote drawing on reverse side. /_ ate: The apP _ Title: Signed X_—� J �.- M / Or Q� �5•� CY FOR DEPARTMENT USE ONLY Area , / y, Date -e?•! AppiTation ACCOpted hV — T" _ /✓ / �y, •. `' Date –"-- Final Inspection by 1!✓� Pit or Grrut Inspection b` ---------'T _�✓.�%1p Tracy 835-6385 Addironat Comments: Lodi 36b-3621 C7 Manteca 823-7104 P.O. pox 2008, St4.,CA 95101 ❑Stk x666791 ApDlican;-Rot6rn all copies to: Environmental Health PermitlServitos 1601 E. Hazelton Ave., CK■ DATE PERMT NO. ` --'�— CASH RECEIVED RY FEE AMOUNT DUE AMOUNT RF MITTED - t INFO 70 ab i (1/1/-2e -.. i 1