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" APPLICATION FOR PERMIT ' +° SAN JOAQU,IN`LOCALL)HEALTH DISTRICT y' k: 1501 E. HA2 N AVE STOCKTON, CA -•. Telephone (208) 485-57$1 PERMIT EXPIRES''1'YEAR FROM GATE ISSUED`^ 4 wvm T7 ap>•.-.la t0 •. ix, (ct7mp19os in:Tnpltce;e) ..,M tt ..: 'CS`Sx7'149fi tr. 3r '.ttI S 4..»RLrMf. 1�i ...itf 0. 0,iz n:. P.ti tl f..t.UO.y p—v'. a_.•.,. `Application is hereby made to ftSan Joaquin Local HaMth District for a permit to construct and/or irrtal tits work hrdn dycriAad.:Thip appksdon is made in compliance with San Josgil Ctwnty Ordire ce No.50 for sewage or No._10102 for wall/pump and five FlOss and ReWiafiolvs of fha San Jos it Local Health-Diatrict. O{'h /•:" .'V'•" .'s'v.. , ' lk 1. • 4 e i. n•? ti++ S, - .it'•} :.wry i .,iw. •b •. . lcOtt, 'df+>:,.. ,f :,:g r i,�.a. 4 i.Mfltl ' tv +' ..•;�°. ' y�aW43yw 0. .: Ri . ,a .j5q" .V>4^+ V Job Address �yy�R v�.TA., H�Ie✓sF1I/ t. -T ! •`t7. .:.,gh,' -.�+l.oi$6e "!D/ tnt pjll ' .:f Y r it4al"')T�ff..14t M. "tt,y.1..9 [H' r1:1:,Jn ^^_ tf`.. tt.l':t C '.I, *f., . 'r. Owner's Name- 3-dJM WA**-A' =Address'- -.iAia46 - _=: :L.ex=:r- Phone CGKL .�ty�.y�lfi Contractor �Pv ' Aderecense*No;-6��=�!/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ - •-s_, PUMP.INSTALLATION 1 SYSTEM REPAIR"❑ OTHER O 1 DISTANCE TO NEAREST: SEPTIC TANK ( SEWER LINES DISPOSAL PLD. PROP. LINE t Yl�k�� FOUNDATION AGRICULTUREWELLOTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS -Cl Industrial a"Open ❑;Manteca Da.of-Wall Excavation Dia, of Well Casing ❑ D'y�a�},'9,'./Prwsta ❑ Gravel Pack ❑Ttacy Type of CaNn6 Specifications ❑ Public ❑ Other ❑Pelts .Depth of Grout Seal - - Type of Grout ❑ Imgation _Approx. Depth ❑):astern Surface Seal Installed by RepeirlWork Done ❑ Type of Pump I H.P. State Work_Dona Well Destruction ❑ Well Diameter: ) Sealing Material(top 61Y) t 1 Depth Filler Material (Below,60 S TYPE OF SEPTIC WORK: NEW INSTALLATION A,- REPAIR/ADDITION ❑ DESTRUCTION,p_{Ng_septic sysrom permitted H pubic eswr k 1 'Q 'i\ �• availaWs,wilMn 200 feet.) Installation win serve: Residence_ Commercial_ Other MeW{ i•. ' Number of living units:�_ Nu umber of bedrooms V - y Character of soil to a depth of.3 feer. SA*d `Water table depth SEPTIC TANK 1D Type/Mfpg 4Ars. /FSC Cw r7 Capacity-Lf-00No. Compartments �• �' PKG. TREATMENT PLT.❑ > - - vY "Method of Disposal , DistaNUIto.ntiarest: Well Wilda /IV •-PfdpEM Una Sftr J T { � LEACHING LINE %I No.6 Lrre--n--g�-�t�h of lines' X " '� 'dotal le tit/size A9 . FILTER BED ❑ `bii6nce7olneerast: Wal �'�r fovavdsfion �.r Pr line p��r �) I SEEPAGE PITS. ... ❑ -Depth L�r.f- .. i-_ :� _ ....♦ .. Number •� `' Y.'X/R 5r :/ XProf r - . r SUMPS _ Distance m rtorrest: Wee JFr Foundation � Pro O r f Li'n'e2 El DISPOSAL PONDS __. ..}. _ " 1 hereby carhfy that I have prepared thin epplic ioh-and-that-the-wodtwM-bErlbn-e in a'Cw dtidce with Stan Joaquin county ordinances,state laws,arM rules and regulations of the San Joaquin Loc il'Health District. 1 S . :•.,-K V+-A Home owner m licensed agent's signature certifies the following: "I certify that in the peiformaifoe of the for.,;".kh this permit is issued, I shall not employ any person in such manner as to becorrte subject to workmen's cdmpajisatiai"aws of Califomis."f:o tractors hiring or sub-contracting signature certifies the following:"I certify that in djie perform ince of the work for whiclh this permit Is issued, I shall employ.persons subject to workman's compensa- tion laws of California." i .�" iI. _ - The applicant must for NI required i1mpectins. Complete drawing ori reverse sits. � {1Sgnad Y' /l _ 'tme:' Daw-r-Al- Ott {171'--,- 1 Application Accepted by + •. •r'/�' -. f ..� f: «�L t'Am 're Pit m Grout Inspection by - 011 ` ..- }.-. ' - Firaal Irwpoetlory bit + L"r' Dak Additional Commsnb: � -• r. + ❑ Stk 4666761 C3Ltxl 3�3fi21 ❑ Menem' 823-T10i . r ❑Tracy 536 _ .. Applicant- Retum all copies to: Crwrmmnwa Health PmtNt/Seivlese 1(d1 X Mansion Ave:, P.O.Amt 2001 Stk., CP.95201 FB Ae1011liT DIIE- _ Mlplgs►JIBATfED - ,-.�N _-..R BY i.. .DATE + PERMIT NO.- viA 1A