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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is mieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dosnibed. This applcation e made in compliance with San Joaquin County Ordinance No.549 for sewage w No. 1862 for wee/pump and the Rues and Rptlatioro of the Sae JOOMM Local Health District. ��j ,�.. � Job Address __ /x`1971 N r/'f// .�sv �V city-Zo a - -' Lee sial. D arc�rl fMl Owrei s Name,,(.r L�.bN ,rCZ1M /C C _ Add,eea, I y�/1.0 �'a Cmtractor UNIllerez &S r _Address License N aId/_d�tr�License No.at 6/ Phona TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ _ PUMP INSTALLATION T' SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Du. of Well Excavation Dia.It Wea Co" F1 Domeatic/Private ❑Gravel Pack ❑ Tracy Type of Comets S1ed6catiwe I I Public n Other n Deib Depth of Grout See Type of Orwl_ Iain Wo _Apprm. Depth naa I Etwn SutjSeat installed by Repair Work Done Il Type of Pump 4 H.P. ,?�f(/-- SIaM Work Dona m Well Destction ❑ Well Diameter Seating Malt"(top N7) a !NI =! Depth Filler Mattie(8alow ED') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo sefltkayesam roorrsilaA it ptllM.larcw Y able whin avaaXV Mt.) Installation ,rill serve: Residence_ Commercial_ Other Number of it"units: _ Numbs of bedrooms Chatacter of soil to a depth of 3 feet: Wale/table depth SEPTIC TANK ❑ Type/Mfg Ctpechy No.cwllpwirwft PKG. TREATMENT PLT.❑ Method of DNpa* plate"to rwwl eel: Well Foundation hrpMv Line F LEACHING LINE Cl No. 6 Length of Wes Tot*WVth/ FILTER BED ❑ Distance to rwrest: Wee__ Foundation Wepanv Lila SEEPAGE PITS I I Depth —Sin--__ &a 6m SUMPS I I Distance to mono: WON,_—_ Foundation—_ Proflwly Link DISPOSAL PONDS ❑ 1 hereby partly that I ha.a praponed this application end that the work wall be done In woordento wish San Joaouat cowtty wdnwK stale Iwo,tatat rules and regulations of the San Jopuin Local Health Diltrkt. Horne ower or Bcwwd agent'O signature cartRles the IollovArp: "I candy that M the nerlorwwtce of the wok 1st wltkh Vb Pwsrlif Is ElwwtL 1 allr11 tall ampby wry pon on In such niannw as to becalm subject to workmen's o»ntpweshort Evans of California."Contraetot's filling as eW oolwaelYtO elpwhm cMlflw the IMovAng:"I anlfy that M the podolmance of the work for which"A INN I Is owed,I alae employ pwawe owills l 10 wVlatrlwye oastperteF ten knee of c*Nomle." The oppilcant must"a jr an n ked Inspacele to drawing on revwee ski. Signed X Title: Data: � s FOR DIEPART111,1119 U1111 ONLY AppliPit of Grout Accepted by ___� Den Area—; -_ Pit or Grout Inapeetbn by Dab FEW IrrpaCtlon by Q„_ Data Additional Comments: ❑ SW 4064781 ❑Lod 36P]621 0 Manton 823-7101 0 Tracy 671:6786 Applicant - Reborn N copal to: Emkonnem*Health POrrNt/Son las 1601 E.Harelton Ave.,P.O. Bat 20011, S*.,CA ES261 FEE AMOUNT WE AMOUNT REMITTED N REfENEO civ DATE FEllklrt"top, INFO -30-49 0 sou baa.