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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 5+601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIRES 1•YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hasby MUM to the Son Joaquin Local Heath Disalct for a pemtit to oort bAW and/or Install the work heroin described.'hds appgeat6M is :!►ads lo compliance with San Joaquin County Ordin wwo No.649 for sawage or No. IOU for well/pump end the Ruh"and Regulation"of the San Joaquin Local Health Dixtrkt. Job Address 32416 r-4ur i=AF-moryr s city Sr0CACJ'o*tl Lot Slze--I eoo 1 ---- 1'M ZtYIo cl Ab'd+o 02A. C Owners Nam* 6 ICpry 4r"" ,PWC, Address 5WA' rel000Not C* StIT11 167E de&A'1o4. 40, Contraetoelrr t� �t16se. �,s+kl�l�dress ,Neon. t�"sSIS/� Llcen,e No. dt�'�� F'ir TYPE OF WELL/PUMP: NEW WELL;3 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 9. SYSTEM REP IR ❑ OTHER 0 DISTANCE TO fJEAgj;SL SEPTI�yANK. o oJW f R Sa �QIS�SAL _PROP. LINE �Q FOUNDATAN AGRi NkTURE,WFU. OTHER WEL t7 PITS/SUMP$ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑Open Bottom ❑mantaco Dia. of Well Excavation_ _ r r., Dia.of WOR Casing r. ❑Domestwpnvate OrGraval Pack ❑Tracy Typo of Casing V c Sp*cificatxons a.oFe f!m ❑ Public In Oder JKDelta C ash of Grout Seal �a Type of Grotrl oesefft +lt yW6Ar�re!r4 � pprox. Oepth fIEastam Surface Seal Installed byZ�+�4►�d@ lr4r,4 -2A;4!jN¢a„ /•vc. - Repair Work Done 0 Type of Pump H.P. State Work Dona Well Destruction O Wen Diameter Searing Material Itop SO1 Depth Finer Material(Below 507 "vPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION 1 I (No septic system pennitled U public sewer Is available within 200 feet.) nstanation will serve: Residence____ Commercials:.;,., Other ' umber of Wing units: Number of bedrooms__ Character of a A to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _. - Capacity-- No.Compsrtrnents PKG.TREATMENT PLT.O __ .'.. ._ Method of Di gmal Distance to nnarest: Well Foundation Property Line LEACHING UNE ❑ No. 8 Length of lines Tota!leragthlsize FILTER BED ❑ Distance to nearest: Wen Foundation Property line SEEPAGE.PITS !'l, Depth Numb*; SUMPS 11 Distance to nearest: Won Foundation Property Line ~+ + DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo rubs and regulations of the San JoaquAn Local Health District. squirt t aunrr ordinance+!,s a!o laws.and Home owner or licensed agent's sign-•.cre eartifm' the fonawing: "1 certify that In the pedomunce of the wont for which this pum>it is issued,t Stan not arrtpioy any person in such manner as►a become subject to workman's compensation lava of CoMormis."Contractor's hiring or sub-!:overacting signature axrtlfees the fda ting:"I certify th"in the performance of the work for which this permit Is issued,I shatf employ person"subject to workman's eompsrtsa- tion laws of California." The applicant m it on tequirpff inspections. Complete drawing on reverse side. Signedif 7 �' TWO. "�r0. ¢dO l y t � Oate: /9 4/ l T O FOR DEPARTMENT USE ONLY C _ Application Accepted byDate I' / 0 4 Ares �3 oh or Grout Inspection by Date Final lnspoction by Date - .fddilkwW Comments: ❑Stk 486-Ml ❑Lodi 369-3821 ❑Manteca 823-7104 ❑Tracy 8354M Applicant•Ratum an copies to: EnvironvIumal Hoslth PanrWSarAom 1!101 E.Hazatton Ave., P.O.Box 2009, Stk.,CA 96M, INFO AMOUNT DUE AMOUNT REMITTED CASH Coe RECEPAD By OATS PIcR147'04. , EN trI+IREV.tienF ��-•s'� qG.�,1�G