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_ %Iwo las APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOC1!TON, CA T31ephone (200) 466-6781 PLRMIT EXPIRES i YEAR FROM DATE ISSUED - ---__--- (Complete it. Triplicate) — _ /bpficatioo is Ibtsby to tic San JosaI Local Nealm Osmct fn a pwmf ro conou.r avJ/w tame the leis llook r rinrnMrl.TNle appkkn ca is :rials n HeMh Lalth District.twdr$an Jegen[avNY O:ransrrr�No.5191w sewage w tie.te621w wA'pwnp.rM re elutes ab AepOmbrs W Lti$an JW:,t+m I" / r Job Address ,IAr�p,7�-3�fk,3-{i l), � (�� .FK,.�P.� n Cit Lott Sit(a�b1s 7'�Z Y G31 PMS Ownsri Name Llw^'�eMAA�derSdBi��? Addle.,14a _ �U . ,9 PMro 7+15—/s�S$ V O C) (� Lf r 'l� Contract LAddress.`• �/. L��%��I.icense No,j zy�_�_Pnone3 _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION 0 PUMP INSFALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP.LINE _ _ FOUNDATION -_ AGRICULTURE WELL___ OTHER WELL PITS/SUMPS __ •i\-/ r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LT, ❑Industrial ❑Orion Bottom ❑Monte" Ola.of Wall Excavation Dia.of Well Carl A ❑Domestic/Prbata ❑Gravel Pack ❑Tracy Type of Casing Specifications J 1'I Public Cl Other Cl Della Depth of Grout Seal Type of Grout_ _ V I 1 Inipalion __Approx.Depth I I Eastern Surface Seal Installed by— Repair Work Dom ❑ Ttpe of Pump M.P._ State Wad.Done Wall Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Material(Below 50'1 _ _ TYPE OF SEPTIC WORK: NEW INDTALLATION REPAIR/ADDITION I I DESTRUCTION I I IN.septic system contrition if pudic sewer is {{ available within 200131.1 InstaEatisn wit"'L: Residence Co.n '.al__ Other / yi Number of living units: Numbc.of a rooms Character of.m e depth of 3 test' — Water table depth _ SEPTIC TANK 9 Type/Mfg Capacity No.Companmenu _ PKG.TREATMENT PLT.❑ r r Method of Disposal Distance to nearaD �0 Well-�= Foundation SSL Property Line �— LEACHING LINE ya_No.a Lehi of Imes — "LU Total lengthIsics _ -�y�+� r FIL'-ER BED _ ❑ Distance to,sweat: well.,mar_ Fountlation�Q_ Property Less it 00 r SEEPAGE PITS X Depth _Sita Number _ SUMPS L7 Distance to nEsr3i: Wall r Foundation Prnpeity Line-.�..— DISPOSAL PONDS ❑ 1 fall unify that I haw prepared title applimtwn and that the work will be done in accordance with San Joaquin county a i inincea,silts taws,and y win and regulations of the San Joaquin Local Health Dib rici. Harm Owns,or licensed agent's algnstura 0911111811ins foliOwing:"I certify but In the perfomenA of iris work h,whi&this tannic le issued,1 shall no: _ employany person In such manner as to baconlo sublitct to workman's wmpumahon haws of California."Contractor's hiring or sub�wntrectmg signature gnifiea this toWwing: 'I unity,that In 1be mdomunce of flak work for which this wrmit is issued.I-hall smpioY Patellae wblect U workman's coriper l '{ lien Is"of California." i The spMiccm rrQ\a\L Call,to,^Y',\PrI((N/�U�jpjl�nsp,4_1\\ C,pmplNa dnwing on rove s�es.Qj a/, — Si-r. it%__ \ y`�'LJ' - 2vY—�— Title:_—�L_` L gab: `Ir FOR DEPARTMENT USE ONLY Application Accepted by17--,el /--_—ems-- - 611)o,Grout Inspectlm bY� /) Dale v Final InspecWn Additional Comments:Cl Slk 4554781 O ImE 388.7821 Cl Morisco 873-710/ ❑Tracy 5368080 Stk.,CA 55201 t Appllcem-Rowan nil copal meMV to:Environmental Health PmServkm 1001 E.Saltation Aw.,P.O.Bair 200% iEF AMOUNT WF AMOUNT FEMITTkD CUSH BY DATE 'iRMtT'NG. - 1NFd -/— .EN rsmlasv.„ee �w;) Y/-/clo �".,�. O � cel tor# �-YY