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L y° APPLICATION FOR PERMIT '17 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (219) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appi"IKwi n heteby made to the San.ioaquin Local Health District for a permit to crntstrucl and/or In►1ab the work herein desctibsd. INa&OPkapon r nlyda n Currµ,4a11c Y Willi Son Juequ n Cuunly Oid,r#ern a Nu.fa191W$sWelfe a Nu IW fur wYIU pulnp an i pilo Hulls and Rogwationis Of the San daiequin LUC&I Heailh tNbt,K1 D Job oauiAre$s 10 1 f (�1 E 21 Yt NaC C?o.y ` k Ct11 !J _ Lot Site l rl ri PM 7 It _ Owner's Name ��_-- �� _----•--_--- Address ___..•_._..---- _---- - ,-�--_ Phor1C71 3)74& ` Conitaclor ,�.L �'►�'j_IEK�IP' Oress Z _.�t%'1 l�_license No. _?—•,�P?ze ` pleas S 6 IZ ' TYPF OF WELL PUMP NEW WELL I WELL REPLACEMENT FI DESTRUCTION A PUMP INSTALLATION (I SYSTEM REPAIR 1 1 3THER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ---- DISPOSAL FID____._ PROP. LINE _ - - FOUNDATION .- _ AORICULTURE WE_LLOTHER WELL __ _. PITS_ /SUMPS_: INTENDED USE TYPE OF WELL PROBLEM AMEA_ CONSTRUCTION SPECIFICATIONS Il Ind.ectal- U Open Bottom l 1 Manteca Dia.of-Well Eatovatlon r1 n -_-_-....- Dia,of Woo Casetg I I Domesl.c/Plrvatw I l Gravel Pack 1 T Tracy Type of Caaalg.`�!�+. p Specdutlor, I'I Pubic M7 Dthor 1 1 Della Depth of Ekoul Seel -..- -- _-- Tyof(pout � yrl��1 Lit l� -10Ap1MUx. Depth I I Eastern Eiutlow 6"Installed by PJpur��w► ')e><rw Type cel Pump _— H P. _ _ --_•-- - Stale Work OUhQ Visit Destruction y- Well D,ahwlei 60411141 Material atop b0'I - Depth 110 �.� _- _ _ filer Material IBebw 60'1 TYPE Of SEPTIC. WORK NI W IN'--,IAI 1 A IlON I I 1111-A111,AnDIIION t I UISIMICTION I I INu wpt#c sy►leii lNntreltYd of public sawwt Is evadelle within 200 feel I Insiaaatoun wall serve: Res,d"itce Comnlart ial Olives _ •__ --�. _ - Number of living units: Number of tKKlruurns I Character of soil to a depth of 7 feel: - _--_ _ --- ----—_- _ _ (Yale, 1,11,14 depth J SEPTIC TANK I I T /Mt r YPw p --_ - Capaacdy Nu CunlpalUl.I„ter PKG TSIA1MENT PLT, I I AI,n ,l of Uy ,pal -- Distance In nemsel Web Foulidetum Prup.eny Line =_-- fN /+ LEACHING LINE 1 I No III Length of laws Lula)lenuthn' it FILTER BED I I Distance to neatest Well FuundalKm W,perly INw SEEPAGE PITS I DVplh Site NunttJwl SUMPS 1 I DIsionce to nameal: Well FuumialKin _. Pfol#wfty Line DISPOSAL PONDS I 1 I hereby certify Incl I II.+e prep«Ied this appuulion and that Mir Wink will be#l,nu III al[Ulitance Willi Sen Jurgen county ordowices, atalw taws, anal rules and reoulauuns of the San Joaquin Local Eteallh Dillnel. �^ Horne owner or licensed agent's st.naturu carldw-the lullwvinl: "I Andy that in the performance of the work lar which this paiinrl Is Issued,1 wwal not employ any person in such manner as to(»come subject to wuikman's compensation laws of Cellornis”Corgia,lur s hauly w wt.,wdracwq signdlure cenifies the following:"I candy that in the performance of the work foe which this p oinat to#$sued,I dull employ puteons aubp.Lt to Wurknlafl s GompW%a4 tion laws of Coiloinw." i Tnt he appiybsl tail for all uit ins I . Complete drawing oil cow"side. Signed X� tC -. Title: �e`.1`y� Data a) 0 11,14 FFQR DEPARTMENT USE ONLY c Application Accepted by _ C- '- W.._d `a"" �S Date `�.'i�s� Alves Pit or Grout Inspection b r spa Y —. Dille Fmd Inspection by Dat. e� / r Additional Comments: I Sik 466-6781 0 Lodi 369 3621 11 Matilecs 8237101 Ll Tracy R3,&385 Applicar.i - Return all copies to: Environmental Health Permit/Services 1601 E. E:azuitun Ave, P.O. Box 2009, Sill, CA 96MI Lci+ -�•+�.. ,,.1�rd�,. dcI—i ,ai k 4-1.- '�+��.v�ci,.....:� t�d r Hca� ! Tel INTO AMOUNT DUE AMOUNT N iTTED C S"N RECEIVED By T DATE PiNKA h0 IN 1J 1a iNtV + �. p 1