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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �^ Telephone 1209) 468-8781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fCornplete in Triplicate) Application is hereby made to the Sen Joaquin Local Health District for a permit to construct and/,,, the work looks deacr6ed.This app6eaaon is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 far well/pump and the Rules and ReglYllorr of ore Sea Jnwfuln Local Health District. /,l r7 j A Job Address _ i SZ 7.r✓. E• I1z T/ Ems ' CRY 4 / M00 �Lsott Sim to �G PM Owner's Name P,r leC LAIf', 1p�ddi.r 311 W 6ft&/ e' .V 20 Phone 394 - Contractor It Address 75/87 6,04 4:32ALicense No. 3q!SyZPhom 4' 130 TYPE OF WELL/PUMP: NEW WEL0K WELL REPLACEMENT C DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 'Lt�^ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLD./A9• PROP. LINE JAQ FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO C Industrial 'Open Bottom ❑ Manteca Dia.of Was Excavation Dis.of Wall Cawtg Domestic/Private f i Gravel Pad ❑Tracy Type of dWw41 SpadB nj" C Public i 1 Other ❑ Delta Depth of Grout Seal A Tyle of Grout C Irrigation 'L b Pprox. Depth ❑ Eastern Surface Sall Installed by Repair Work Done Type of Pump H.P. State Work Dore Well Destruc'ion C Well Distretm Sealing Material(top 50) Depth e.PRJ— Fiber Material(Below 60') TYPE OF SEPTIC YORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION L] (No septic LynamP;:ttad B Public saws is avexebis withkt 200 feat.) Installation will e�Reaidencs— Commercial_ Other NumLar of living units: ��I r Of bodmoms Character of so'1 death f 3 rat• Water lobe dsDih SEPTIC TANK Typs/Mfg C nv No. Compertrrents PKG. TREATMENT PLT. i- Method of Dispose Distance to morwt: Well FouRr ion A Line LEACHING LINE No. 6 Length of Imes Total length/era FILTER BED Distance to notion: Wall Foundation Property Lire SEEPAGE PITS Depth Sire Number SUMPS "- Distance to more Wall Foundation Prop"Una DISPOSAL PONDS L I hereby certify that I have prepared this application and that the work wM be done In accordance with San Josquln county ordinances, nae laws, aha ruin and regulations of the Sen Joaqulm Local Health District. Home owner or licensed agent's spnsture oertBles the fosowing: "I certify that in the performance o1 IM work far which this permit is Issued, I MM rpt employ any parson in such manner as to become subject to workman's compensation Iowa of CdBornis"Cononctor's hiring or sub-contracting signets" canities the following: "I certiry,that in the Performance of the work far which this Pemmt is Issmed,i slur employ persons subject to workman's compnea� ton laws of California." The applicant m c 'for all requbed 4pecton em drawing on reverse sine. p Signal X_ ..C_ _ w��LiTiIN: �7/Lf�. Dan: �7d / FOR DEPARTMENT USE ONLY a� ApdicaGnn Accepted by I/�� Date j/ Sys AIN Pit Grout Inspection by �'—T!'�`U Dan - ��-` FNal Inspection by w9 ' 7LLl. 6o:.— Dan Additional Comments _ - C. Sok 4666781 Lodi 301-3621 ❑ Moo n 823.7104 ❑Tracy 835-SM Applicant Return all copies to: Environmental Health Pemat/ServiNa 1801 E. HaaMton Ave., P.O. Sm 7009, Stk., LA 86201 FEE AMOUNT DUE AMOUNT REMITTED U9H RECEIVED BY DATE IERMIT'NO. INFO I I E . lee wars sry - UU CA'1 0•lv� (•��b I ?- Ea mt 7a