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APPLICATION FOR PERMIT <br /> SAN JOAIIUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON. CA <br /> TeNOW* 12091 466-671!1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> --- (Complete in Trinfitatel <br /> 5 <br /> Appwcatnn n h4"obv mads to the San Joepuin Local Heald+Dostr,ct 1fcfl a perm"to cansduel widfd foie& WS6ea My Eon jewita n <br /> mads,n cnmobsnce with San Joaquin Co,rnty OrA,nance No 549 fa aewvape M No 'Rti?fp w ea'Prr'tP <br /> L dial Hearth District <br /> _�I�� _ Cm kt� la Sin _ PM <br /> Job AArt+sss IL <br /> Owner's Name <br /> Contractor °(1GN��' _Address._~+ __-LKense NO ►aerie <br /> TYPE OF WELL_/PUMP NEW WELL LJ WELL REPLACEMENT I DESTRUCT" 1) <br /> PUMP INSTALLATION n SYSTEM REPAIR (l OTHER CT <br /> DISTANCE- -iA�S>-T SEPTIC TANK SEWER LINES - — —dSfaOSAI fl0_ - PROP IMVE - <br /> �FOCJ ON -� AGRICULTURE WELL _- OTHER WELL_. PlnfStlMPS -- <br /> INTENDED USE TYPE OF WELL AREA CONSTRUCTION SPECIFICATIONS <br /> _ - ---- --- - -- - <br /> trMntrial — (. OWn Bottom f)Manteca of Well Facavation Dia of WM Carq ___--- <br /> Oorr+estKiPrivate Gravel Pack Tracy Tvpe of -_ _ Snsrfaatwona <br /> i" Public Other Delta Depth of Gr,wt SMI _- Two of Grout - <br /> Irr,gatinn Appros. Depth Eastern Surf ac*Ssat Inst~Isy - <br /> 9epair Work Done Type of Pump _. .- _ - --- H P -- Stses Warn Dan+Well Destruction f 1 Wes Diameter - <br /> Depth - ------- Fdlsr Mater+al IBe1ow 501 .- --- - ------ <br /> TYPE OF SEPTIC WORK Nf W INSTAL CATION IV' nFPAIP ADDITION OF S' tt/f'TtOa/ lin saphc svl w"permriM,1 P,4AK *W~is <br /> l. / avadabka nwthiri 1Q1 feet 1 <br /> installation w n xrve: Residence--_ Commercial _ 'Oth« <br /> Number of living units: __L_ Number of bedroom$_ 5 _ <br /> Character of soil to a /6I 3 feel. _ __.-_. __. _. Ws*sr rsble loot* 1 <br /> da�ff� tLl1- - - - <br /> SEPTIC TANK �1 Type Mfg 1-___ -_____-_ __ Caparfly J�r►O- No Cnmpart^+^n _2L, - <br /> Method of D41100" ' <br /> PKG TREATMENT PLT ( 1 _ <br /> - r i <br /> Oistance to nearest- Wan FainAahon Property L+te If <br /> LEACHING LINE No. A Length of line- 13 If--- <br /> Total Y+tglh/>rm �--- - <br /> _._. <br /> FILTER BEI) i Distance to nearest. Wen y<rc'.. Foondatlion __._ Propatr Low .23 <br /> SEEPAGE P,TS Depth Site <br /> SUMPS i Distance to nearest -Wen _. Fpuidahnn - Property Low <br /> DISPOSAL PONOS <br /> C 1 hereby certify that 1 have prepared this application and that the v 1, AM tie dnni,m acCnrnance wth San Joaquin county ordwoxires sora laws. and <br /> rules and fegulabons of the San Joagwn Local Health D,ktr,ct <br /> Home owner or licensed agents signature certifies the following -I certify that m the performance of the work for wft,th tows pamwt is issued 1 frTaatnot <br /> employ any person in such manner,as l0 become sublw t to workman s compensai,rin laws of Cakfo,n,a Contractor's hwtrq or SuAcontract sgna <br /> certifies the follnwing "I certify that,n the performance of the work for which this permit is,stied I shad ernplo'Ir suUMct ro *mins cornpenaa <br /> lion laws of Caldoirna" <br /> The applicant must call tot an required inspections. Complete drawing on reverse side <br /> - �y�r V - S <br /> y /4� !eJ, fI- T-tle .1 ;'rt L- ----- -- Date' <br /> Signed X___�- ` <br /> DEPARTMENT USE ONLY <br /> n ` r <br /> Dan Arela-----a--'l— -- <br />