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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL F!EALTH DISTRICT ?F!)1 F HAZE ON AVE. STOCKTON, (,A Te:Pf:hone 12091 4i,Fi 6791 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comnlere in Trinl!caie) Apl drt•anr••r rs Ivr.•6r mode to the Son Jnagwn Lora:/IrnRh D•s!n.-1 for a r o,m!t rnn•!rtxT and Of rnsta11 the wrtrk tieren described.This application i1 mdtr!rr,[ornl dean'.. vnth inti,.Ir.d�l inn Cr�rn!r Ordnnn�u tin }i9 h•r Sr'•o•Vie nr N•r le•.;tar wrrlr•„imp an.l inti Nates erM Re�agtTofls of the San Joartinn I.r rig Ileranh O'sir.r i cr VA I'm!( C. - Lot Srie_ _ PM -I Ownrf'sNanw! ��t�.eS _-_- �!_� 1 ' _ Address __..__Sa'�1✓-_-.____-. Phone C_,_---- ��,, l/�l! A?a•r•sc /1^ / L:ceme N. y �r r Phonej;tF- Conlra�lor _/LML•te�.---C ""--� - ---•'��'-- -- �-U- LQ♦I--�-�- 'iYVLOF VI/EtLWOMP NFW WEII WELL REPLACEI.tENT DESTRUCTION i. PUMP INSTALLATION SYSTEM REPAIR '' OTHER (•) DISTANCE TO NEAREST: SEPTIC TANK _-_-_ SEWER LINES ________ DISPOSAL FLD__- _ PROP. LINE _ - ... FOUNDATIOtL AGRICULTURE WELL _- _ _ ^THER WELL__ P1TSrSUMPS INTENDED USE TYPE OF WELL PROFILE%I AREA CONSTRUCTur”SPFCIFICATIONS i 1 Industrtal I Open Pon,xn Manteca Du of Web F.1.draf•rn-__— __- Dw.of Wel Casing - It Cornesfa•Pnvafe �Gravel Peck .: Ttacv Type of Casa.g Specifications Virl>lir. Oft- Della Depth cat l,rntit Seal --_ T1pe of Grout Irrnparion .. Antva.. Drpfh t I Eestern Swlace Sed"Inara.'Wrl by --- Rclijo Work Done I Type of Pump -_.____ H F —_ State Work Done__- Wcn Dest,uct-on Well Diarr,rfef __. - Seakng Mater-al Icor 1,0't _--_--- __-- - Orpth_ _ -__ _ FAkr V•era�al IRek1w I _ —_ -- .7Y(L Of SIP11C WORK. NEW INSTAI tATION 1 ! R(F'Atk'..DUtTION UESTPUCilON INo septic Sys•rrmf permned it prrtdre Sewof rs '/ avafleble wrthint 200 feet.I Instaf4hon vrrll stove: Residence_`T__ Cemmercwl_ OtherC0 Yurnbm of(wing unnst _—_ Number of bedroorns i Character of soil to a depth o!J feet:_ ._-^_--_ ___--_ -Water table depth .__. SEPTIC TANK II Type'Mfg - —_ Capacity. No.Compartments PKG.TREATMENT PLT.E1 Method of Disposal De.urtce to nearest. Wel Foundation_ _-__— Property line_ LEAC14ING LINE. I-) No.6 Length of lines ___ ---- __ _. Total length/sire FILTER RED •, I: Ewar ce to nearest. Wrsl Foundatrrxt-._. Properry Line SEEPAGE PITS I Do"th __-Site --- SUMPS t Dwance to nearest: Wel !-_ Foundation ___..-._ Propeny Line ,n DISPOS' p)NDS I I • 1 twetry certify ttal I have Matured dos apptiLA!fon and thvt the work.,fl be dune m a,crntlince vwdh San Joaquin county ordinances,state laws,and rukts er:d r'bqulstotn of IM San Joaourn local Health Desired. Homte owner to(K.ensed apam s srgna!we Eefldfee the tosowrq- 7 certify that n the pedorrrbance of the work for which this pen,1 sresi I stsMl not9 errytoy orry person in such mbarwsa as to becor"s subtect to wcvkman's compe.Tsatron Lbws of Catrforree-Contractor's hrreb0 a watonbat corn fm IM folov".'•I comfy the,on the parol mance of the work for whvch this pplml 6 asood,I ahA employ persons subprict to workman's eornpensis tian tows of Californa." The applicant inert cas for eft-w rf+ed nepectrons.Comfttete drswep on reverse weir _ l Signed X _�/t JA.. �'—- -- -- Tnw.-- _'i Vu -.. ._ _.._ �- Darr. R D7!P/IRTMENT USE ONLY Application Accepted tri ��rMn ---- '- ___--' Date -.^ A 1 ,7n or Grout Inspection by Date_-- Fvu'Irtspect:on VV \ Dota�� f A;ditwnal Cor.,lnenu: C7!:Ik *A-G7S1 O Loa 3®3621 O Mentors 47 7104 ❑Tracy MS&M ro Ap:ilcont•Retum all n copies to:Envaonrntal Health Pwnrt/Servxn 1601 E.Hatehun Ave.,P.O.Boa 2(109,Stk.,CA 95201 r _ FEE AhsDVNTWE AMOUNT AE WT'.FD �k hlCEnlED eY DATE PERM"No. tNFO _AyN _ - .IM lite IRFv f'• y24-• 3- o^ 8� tM fa XI it �•`tr It .f t'y