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APPLICATION FOR PERMIT - I / SAN JOAQUIN LOCAL HEALTH DISTRICT I MOT E. HAZELTON AVE., STOCKTON, CA ,` } a Telephone (2091 4W-9781 ' I l PERMIT EXPIOES T YEAR FROM DATE ISSUED �i (Complete in Triplicate) s a App;cetion is hereby road,w the Can Joaquin Local Heelth D*rkt lot s permit W tendril and/"Irvall On work heraln dnct6rl.The G1P6eagOtt M ._ made to comollence with San Joaquin County Ordinance No.549 for aewoge or No.1962 for weglpmp and the Ruin Ind RapuYtloltlpl the$alt JaWN ,_ 1 Local Heahh District. t JobAddress. 1�L'�V` t n�a` CitT..]"1kjL�k— Lot Flu_ PM Owners Nsnr..��W LWA, % _Phone 1 Conlractor'a Name E SA I PitTheiu—1 erne No. —Ph" �F TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION Ll tn PUMP INSTALLATION 13SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__ PROP. LINE FOUNDATION_ AGRICULTURE WELL _—OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS— ❑Industrial C-)OpenBottom El Menace Di of We Excavation Dia.of Wall Ceiling C Danustik/Private ❑Gravel Peck ❑Tracy Type of Casing_ SpeciFuWn, ❑Public, ❑Omer ❑ Delta Depth of Grout SPA] Type of Grout ❑Irrigetion __,Appok.Depth ❑ Easter0 Sudece Sul brdeped b/ Repair Work Done ❑ TyPe Of Pump _— H.P. SPIN work Done [ - Wal(Destruction ❑ Well Dlametr __ — Feeling Malarial(tap ED-) t Depth _ Filler Material(Below SO'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION❑ INo split aYataln Pmmirtad 9 puck,akar Y. ,vellsble within 200 faet.l 9 fnKleitian wia verve: Reeidance_ CanmeneW«'L — IS Number of Wing unlm_ Number of bedrooms _ X Character of,oll to a depth of 7 teen table depth SEPTIC TANK O Type/Mfg ry .Compemtwnn PKG.TREATMENT PLT.❑ �L/L y 47 Method Of 0I8POOM Is - g$L Dieunce to roere+c V/ail Fwmdetion Property Una $ LEACHING LINE ❑ No.6 Length of limit __Tout lenglhiairs �I FILTER BED ❑ Distance to merest Well Fcundatkm Property Line l SEEPAGE PITS ❑ Oerih She_ _ Number Vt Y SUMPS ❑ D'+unu to sarin: Well Foundation_—Property Liles ?, DISPOSAL PONDS ❑ �I 1 hereby unify that I have prepared Oda application and thet the work will len done in accoldi nee wKh San Joaquin county Oidfollin ea„OWN laws,and P F rubs and regulations of the San Jopuin Local Health Dlatrict. ' 1 .� None pwrwr or liuneed agent',signature cenlfa the following:"I Part"that in the perfgmenM ut the work for nitkh this pe rnh Is blued,I(hall rot tl pby airy preen in eueh"mr er m to becomes aublect to w nuns li a eompenutbn taws of C,IKomia;'Crn1TWOrra hkkq W eubCMVaLYNrg 04fwtum F u the failowing:"I h�tlhf Thal In the pHomwnce ai rhe work far which thN prrMt la leveed,I ehaq employ)',rents subject m work '10 CarryerlM,•,' ¢ ileo la Ctl9por b; The Millicentecall t;.all qv ed In axion o doe drswieg 1yonse ids � .A Figured Tule: .>�71 /�A7 _ Dau: J ot9"6 1 EP ENT USE ONLY Application Acuptad OY �rM Dare AZ-,2iQ_-W Pit or OmitInapeo' Final Inspection b Additional Com ta: ❑ cqk [01 Lod 369- 1 M tau ®7104 ❑Tire Applicant-Flattic IQ: Environmemal Health Pannh/S lees t I.E. eeehan Aw., P.O. Bos 2009,Elk.,CA JIM, � FEE AMOUNT DUE AMOUNT REMITTED CASH RECENFD eY DATE PERMIT NO" INFO M I'm SROUa-0��