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APPLICATION FOR PERMIT y SAN JOAC:UIN LOCAL HEALTH DISTRICT _ 1GOI E. HA2^TON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r,pplicetion is hereby mode to the San Jcaquin Local Health District for a permit TO construct and/er Insall the ,it heroin described.This application is made in compliance with San Joe loin County Ordinance No.549 for sewage or No.ieC2 forwell/pump and the 149 and R�st/01!66 -_lDJgequ n Local Health District. Afif-� �� Lot Size _�• 9—��— Pitt-- Job Address 1_�-s-�-�xe, x EGS OJ/L-- Phone6-on- 7'�' Own..a'c Name ' D Address L�'��-a�'-�Ge�� /19E L_�J_�FL�__ _-�-(�y�i p?E, �/�lA License No. '��- --- Phone Connector's Name "L _CT ❑ TVPE.OF WELL/PUMP! Nc,V WELL ❑ WELL REPLACEMENT ❑ PVMPN'STALLA PION ❑ SYSTEM STE!d REPAIR :� OTHER ❑ DISTANCE TO NEAREST: SEPTIC;TANK SEWER LINES _._ DIdPOSAL FLO. PROP/LINE FOUNDATION - AGRICULTURE 1VELL OTHER WELI. _PITS/SUMPS__ IVTENDEO USE TYPF Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca Dia. of Well Excavation_-- Dia. of Well Casing _ -' I•dustrial O Open Roaom ❑ Specifications Gra rel Pack D Tracy Type of Casing C Domestic!Private Depth of Grout Seal _ Type of Grput — �� public C Other C Dolts —�lpprox. Depth Cl Eastern Surface Seel Installed by ❑irrigation H.P. Stets Work Done._- �• Reunir Work Done ❑ Type of Pump _._-- Sealing Material (top So') -- O Will Destruction ❑ Well Diameter --Dili 'Mat—a' —_ _ Filler Material(Below 50'1 TYPE OF SEPT—N!`W INSTALtAP ON _ REPAIR/ADDITION is IESTRUCTION G BNei,blei within fee ittetl�f public sower Is �mP/./tee nstellatipn will serve: Peudence— Commercial� Other ---t-� Number of living units:-- Number of bedrooms -- W:.;er table depth Character of soil to a depthpt 3 leer-.�� No. Compartments -�- SEPTIC TANK P- TVoe/Mfg _(rf✓----L L Ca aci Method of Disposal -_-- PKG.TREATMENT PLT. J �z Property Line$��-- Distance to nearest Well a UO Foundation 7�-- - "CD _ _ r �--- .... ! r Total length/size - -- LEACHING LINE uT" No.&Langth of lines Property Line S� rt FILTER BED Ei Distance to nearest Well_3L- Foundation —__-I _ 'p/DePtlt _ .._SizeNumber�-_-- - SEEPAGE PITS Foundation,1GA, Ptopuny Line�--- SUMPS ❑ Diss„ce to nearest Well�_ -- DISPOSAL PONOS , ��- hereby ourtify that have prepored this application antl that Cho work will be done in accordance with San Jpaq Wp county ordinances,state Cews, er< , dormance of the work for which this pelma is issued, aha(•not rube end regulations e' the San Joaquin local Health District. n tion la.vs of California:'Contractolsubjecteo woring 6z �kma els coreNnsee Name owner or licensed agent's signature certifies'he following: 'I certify that In:ha pe I shall employ persons employ any FArson in such manna(»s to become subject to worka worall'sk niche sa certifies the following:"I certify that in the performance Of The work for which this Permit is issued, tion laws of California.' The appliram must call for it required in/ssp''ecttions. 0/OMP(ete drawing on reverse ssiid, Data: - --��y�� ,e:J'•' //rTJ _.— Title: 2?b.2--_--- signed:� � 'T FOR DEPARTMENT USE ONLY �✓/ ' Date /U Z J _ Area Application Accepted 61' (�� 1Date�� � Z�+C'�Vete C 5 -- Val Inspacbon by--J- ” rylt or Grout InsPecticn by Additional Comments: �— Tracy �+`' G SM aSB-�1 �L;l' 369 3621 t- Manteca 823-7100 P.O. Be,2008, Stk., CA 95201 Applicant - Return all opus to: Environmental Health Permit/Servioes 1601 F. He Ave.. GR a RIOENTO e'! DATE PERMIT'NO, F.E AMOUNT DUE AMOUNT REMITTED CASH INFOI-V ;c-24-�4' 41f—/3 E. v 1�A