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APPLICATION FOR PERMIT old .10 0'f'1"LC 04 SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON; CA red Zy' Telephone (209) 466-6701 1'1.0 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ^(Complete In Triplicate) Application Is hereby made to the Son Joaquin Local Health District for a permit to construct and/or install Ilia work herein described.This application is made in compliance will San Joaquin County Ordinance No.649 for sewago or No. 1857 for well/pump and'Ihe Rules and Ragulallons of rhe San Joanuin Local Health District. , r _ •s. Job Address 14w u City za . Lot Sbe_ '�`�, PM J0 Owner's Nams _�]'c r,L�/� (�((eLJAddress Phone ./ S�V ArFN�- 1Dw1 li{Le/�� 3-21 %6,� r Con �. I hasla h+`I�$�1 � 5mys _,_Adawsslnj_9'gO,��Jr cuf—cu� Phone II TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q. DESTRUCTION U PUMPINSTAL}ATION 0 SYSTEM REPAIR ❑_ _ OTHER 0 .,OISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. '-- "pAbPfttNE � -; i __FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS C`INTENDEO_USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Indundai r7 Open Dotlom ❑Manteca Dia.of Well Excavation Dia.of Well Casing •0 Oomealrc/Private - ❑ Gravel Pack O Tracy Typo of Casing 9pttificatbns PI Public ! f.T other - 1.1 Della Depth of Grout Seal __ Type of Grout 1111 N 61falion —Apiwok. Depth I I Eastern Surface Saul installed byT _ Re alt Work Done' ❑ Type of Pump H-P. State Work Done _ Well Desuuction' 0 Well Oismater Soaling Material(top 501 I I Depth Filler Material if Blow 501 STALLATION REPA _ TYPE OF SEPTIC WORK; NEW INIR/ADDITION I I DESTRUCTION I I 1 o cepOc systempermitted it public sowar Js available within 200 leant Instagat�n will serve; Residence✓ Commercial_ Other Number iliof living units:_� Number of bedrooms. _ e�� -;` Character of 401110 a depth of 3 feet: do .. 1 _ Water tl)]"g�+rinh SEPTIC TANK C� Type/Mfg 'G G.iPCAr_7 Capecily d t7 No. comport �KG.TREATMENT PLT.Ot Method of Olspod Distance Io neafssl: Woll 114_0_Z Foundation L Q Property Line.p �EACNINO LINE WNo. 6 Length of Ones .2— D _ Total length/siw_fsr �ILTER BED '❑ Distance to nearest: wen L CD 14 Foundation'.�J/� � Property Line 4st0'4 rSEEPAGE PITS 01fDaplh ±_Sire_,3 •r Numhbr., 3�_ .�2 �J `SUMPS ,t-s ITDistance In noa,OSI777 Well FoundallaM,4, �r 1 I Pimrty„Lias�[.� DISPOSAL PONDS 0 I hereby eoni(y'that I have prepared this apptiution and[hat the work will be donasn accordance with Sa Joagdiri,county ordinances, state laws, and rules and regulations of the San Joaquin Local ffeellh OiIH46te +• .1 -I l ., �.L Home owner a Goosed agent's signature conifrea.the loVowing;J ceni(y_ItlaLin.iha Podomunice of the,work fat-which this permit Is issued,I shall not employ any Person in such mannan as to became subject to workman's compemallon Iesvo of Qrl6fanla.'%C6ntractor'3 hiring or sub,connacling signatum codifies Ilse following:"I Certify that In Ilia Pertormenca of the work for which[his pormlt is Issued;1 shall employ pdrwris subject to workmen x cnmpensa � flon lewd of California.” tel,t; or The applicant must call for w'a ll rrequired inspo0ons. Cemp�lOie d(OwIng oreverse side. S10mcdXI ARAI L e,, Title; E974 14 -------------- Dat0: .4� d./,Lai FOR DEPARTMENT USE ONLY p� -, ,tS! ^APPliruion Accall by ._:_ �s p- i D'a a�•!Z/ .��. Area PI Grout lnspoctlo ata!/` "O FI mpoG'ron rc `T !!Mf Date Additional Comments: ❑Sit 4684181 ❑Lodi 369.3821 0 Montuu• •7104 O Tracy 83S.GXS "• -- \� Applleont-Return all copies to: Environmental Health Permit/SOMcos 1601 E. Retaken Ave., P.O. Dole 2009, Stir., CA 85201 INFO AMOUNT DUE AMOUNT REMITTED CASfI BECEIyto BY j-7 E PERMII'NO ta.tstaty.nasiOL fig -353 M L`