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i f , • AP0LIC..rtON FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.. STOCKTON, CA Telephone [209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED r 1,� !/ � u Y� I}p 7S' {Complete in Tripficate) AF�IiW:on is Ix:rc. 'de to the San Joaquin Ld cal Heald,District for s permit to construct and/or install the work horein described. This application in made in comp;iance with San Joaquin Canty Ordinance No.549 for sewage or No. 1%2 for w0l/pump and the Rules and Regulations of the San Joaquin Local health District. l/J Job Address 7 , � city ��' F1 — Lot ssr8 � ACr L_ PM ! TZr �s9 6 Owner's Dame r\L, Address /Elaf ) r 15J.4-Alf '`Phone' �L -1 r' s Contractor's Narro - {/ 'r J r't �y^ License No. �• ] �r Phone ��j TYPE OF WELL/PUMP: NFAWA%"Wr- WELL REPLACEMENT X DESTRUCTION 0 PUMP INSTALLATION X SYSTEM REP-AIR �] OTHER 0 01STANCE TO NEAREST: SEPTIC TANK b?.j- SEWER LINES DISPOSALi LD.�j1�! P90P. LINE LOLL'/ 1ti7 FOUNDATION 1.5 � _AGPICULTURE WELL _—___OTHER WELL — PITS/SUMPS t`D INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION". T- �I d� 0 Intustrial a Open Bottom is Nlameca Gia. of We' E,c,Ivation—1.L,r'— — rid. of Well Casing Domestic1F,iv3te Gravel Pack Ll Tracv Type of Casing 1'V —_--_.— Specifications x'13 J 5 /6o Z. oublic Other = Delta Depth of Grout Sial W- ' r _I, Type of C, Irrigation Depth Easicrn Surface Sea]lnstdlied t:•, f Repai•Work Done }}-D Tyne of Purnf, .{5' ___ H.P._tt — State Wurk Done.-- WnI1 Desiructionp yam* :fell Diameter Sealing Ma:arial (top 50') - _--- -- �r Depth - _ tiller fAateriaf(':elow 50') TYPE OF SEPTIC WORK: NEW tNSTALSL TION RE:'AIR/ADDITION DESTRUr-TIUN L. Info septic s•�stem permitted if public sewer is � ' available w;,hin 200 feet) Installation.nal serve: Residence— -on mercial-- Other_. 7 7 Number of IiAig units: Numbcr of bedrooms --- Character of soil I�a depth of 3 feet:_ _— — �_—Water i.rble depth SEPTIC TANK - Typoi'Jfy ___.— Capacity _ No, Co'npartments PKG. TREATMENT PLT.is Method of Disposal - Distance•o near:rst: Well Foundation _ Pwp•eny Line LEACHING LIN'c t1c. 5 Lenr.h of lines _ _ Total Iel,gth:sire T FILTER BED Diaance to rearest: We,l Foundation_ hfopery Line SEEPAGE PITS v Dei.•i`t — Sire F - ._ Number SUMPS D.. i to rzarest: Well-_--_ Foundation — Frope'y Line-_-__— DISPC'SAL PONDS r I hereby verify that I have prepared this apolication and that :he work wilt be bon a io accordance with Sin Joagwr,county ordin: I,es, stat"laws, and rules and regulati:ms of the San Joaquin Local Health Distr_:. Home owner a licensed aucnt's signature cervfies the fol.wmg: "I a•tify that;n the po;fermanue of the work,for which IN,perr-ii is issued,I shall not e;nploy ar.y pwson in such manner as to becorae sublrti to werkman's compent.atiun L".r of Car•orria,"Contractors hiring or subcontracting signature certifies the tofiowing:"I cemify that in the performance of the w-urk for which in s permit's issued.I shall employ per•rars sub,e-n to wori to n's compensa- tion laws of Californw.' Th±rpplicant:rust;,atl f-,r all requrr inspections. Complete drawing on rev-rse side. Signed 7C-.— rL Catr: • j.� FOR f}EPARTMENT USE ONLY AnPr;cation er_ceptad by Yv�/ �`•�_---.-_ ` Dale __,_._ _-- Area �fl .�� () . -- T C'C L �� Pit or Grout Inspection b✓ 4 Dau anal fnswcuor by _,4 _ _- Date Additronar Commenis: i/ ---- --- -- - ---- — --- C Stk 46&�Ml Lodi 369 30.21 �1``Mon:ou P23-710.t Tracy 6 rri335 gpplivanl Return all copies 1p- Envrronr••rntal cahh PermitlServ,ce• 1661 E H.!ielton Ave.. P,O. Boa 2009, Sttk., CA 95201 FEE AMOUNT DuE tvo! •':T aEr��'-IED r CF _RICE vE0 9y Dni£ r PFRrvtl7 N0. INFO 'tf r