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t APPLICATION FOR PERMIT SAN JOAQUtN LOCAL HEALTH DISTRICT a . 1601 E. fiAZEL T ON AVE„ STOCKTON, G Telephot%e (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED 4 s jComplete in Tripli0te) all the work herein described,This Application is lance made h San Joaqu n Cour y Orduin inance No. 549 for for of permit NO. 11}62 tot wa tpump atnd the Ruses end Regular;ons o!he San'estjon is Jo Quin made in compliance u,nt Local Healtn District. :R� � ��S— $�a� 101, `� 7aW� _ PM er✓�fi�n 7' USS' � " Lines ice• d • . c+tr Lo: si:e Job Address: �- } + r'(%rLG�rc�� .F-O rnaii�( Phone's Owner's Name �TAC Address ��— :: `` j� Canford, 4J5 GrI�ilrl. 4-TV Address w •� Amold lrtd(A 'ta�� License No.0 �45Si�S Phone Contractor WELL REPLACEMENT 0 DESTRUCTION 0 NEW WELL C7 $Ot` '[�jpYln d>ti� TYPE OF WELLlPUMP: SYSTEM REPAIR C3 OTHER A ✓ PUMP INSTALLATION n DISPOSAL FLD,. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK ___,._� SEWER LINES HER WELL ._FOUNDATION_ AGRICULTURE WELL Q - T " INTENDED USE _ :So 111 166r'in TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS NIA Dia. of Well Casing �-—� pie. of ❑ Industrial © Open Bottom Cl Manteca Weil Excavation _ Specifications [l Tracy Type of Caying — I! Domestic/Private lr} Gravel Pack Depth of Grout Seal Type of GrOut -• 1'i Publ;c I:1 Other I } pelta "'�'� 1 I IniOat;ori .._�Approx. Depth [ I Eastern Swface Seal Installed by __ H.P. ._... ._ State Work Done— Repair one•— Repair Work Bone U Type of Pump Sealing Material(top 50'} _. ` Well Destruction C1 Well Diameter ,._�� Npthr�_w� Filler Material (69iow 50'} 1J r rmilted it public sower is TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 i1Ll'AIRlADDITII�N i [ DESTRUCTION l I available within 200 filet.[ W Installation will serve: Residence,:_ Commercial _ Other Number of living units: I�J Number of bedrOOmt Water table depth_ Character of sail to a depth of 3 feet: No, Compart,nents f SEPTIC TANK ClType/Mfg Capacity Method of OispOaal PKG. TREATMf NT PLT,Gl Property Line Distance to nearest: Wel foundation.— + �1 LEACHING LINE fl No. & Length of tinea .. _-�---"'" Total length/size Property Line FILTER DED L3 Distance to nearest. Well Foundation Number�_�:�-•��-.- SEEPAGE.PITS I I Depth -. �-•-• Sire�.. ___ _.�•. --- I, OiA SUMPS Ll Distance to nearest: Well—. . Foundation __ Proper Line t DISPOSAL PONDS C} stake and - 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin counly ordinances, laws. trutati'and'roptrlatior►i"of (he San Joaquin Local-liealifi-DiEirirt Homo owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued. 1 shall not employ any perapn in such mttnnar as to became subject to workman's compensation laws of CaI'dornia." Contractor's hiring or sub contracting signator certirms the following:"i certify that in the performance of the work for which Otis permit is issued,1 shall employ persons subjs4i to workman's compensa- tion laws of California." The applicant must cal for all required inspections. Complete drawing on�re^Tse aide. Sl9ned x• A iA. �y.AQ ?„�_� — Title, I V t r. Date: "- ' A O P RTfMfNT USE ONLY .J � Date re Application Accepted by — �/ _"6 Pit or Grout Inspection by Data Final Inapect;an byJ Data .rL Additional Comments: O Stk O Lodi 364-3621 C3 Manteca 973-7104 ❑ Tracy 835.13385 9520 Applicant- Return all Copia to: Environmental Heahh Permit/Services 1601 E. Ha:aiton Ave., P.O. Box 2009, Stk., CA 1 FEE AMOUNT OUE AMOUNT REMITTED RECEIVED R;Y bATE PERMIT'NO. INFO ..e►f t13-24(AV.'in') �,.�•�� 3 � 3 9W 14.13 �?