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-- •11 __,0 [.=.L'1 = 91 =IFTi-' -_nnl= APPLICAT.,lbN FOR PERMIT SAN JOAQUIN LOCAL HEALTH DIS'T'RICT 1631 E, HAZEL T ON AVE, S T OCKTQ+J, CA Telephone (X9) 466.67C1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplica*W) Application is hciecy-node to the San Joaquin Local Heap District for a Parr-),t to construct and/or instalthe vrark he-e!n described. TITS aDN'.Caticn is made n co•nplianc:with San Jo;quir.Oounr,Ordinerrcu Plo.749 for ssvx2ge or No. 18152'or tvelupunip sed the pules and ReQJiFti[•n_Of the E3n.JD'aquin Local Health District, Job AddrecS A(.�- city mae ef, 'c Lot Sire `'a rgcrt's PM Owner's Name �eYCCrley h-v�l Pry Accress Y-6'0J -A-c P,y Phan: Contra[tprIAF-11191V-1h0 t rr-2 Soar AddresS &'0C*K LL• Cr-t >A. License no. Y7'ir`S'9,� Phone TYPE CP VV_LLFUPAP: NEW WELL ❑ WELL REPLACEMENT D CESTRLCT,ON I❑ PUNIP INSTALLATION ❑ SYSTEM FEPA;A ❑ OTHER ❑ DWANCe 70 NEAREST: SErTIC TANK 5cNER LINES DISPOSAL FLD. PRCiO. LING FOUNDATION AGP1tULT'JFE WELL OTHER 'HELL FITS:SJNIPS INTENDED USE TYPE pF WELL PROBLEN1 AREA CONSTRUCTION SPECIFICATIONS u ndustr;al 1 Qppn 3-11.1 ❑! Manteoa Cia. Of Well 5XC3V3ti0n Dia. o;Weil Casing '❑ DomesticiPrivatc ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i i Public r7 Other it Delta Derm of Grout Seal Typc of Grout 1r,`•Approx. DCpth I I E3Starn Sursce SaoIr.;:ailed oy' Repair Wwk Done U Type of Pump H.P, State YVork DoneWe!1 Destriction O VYell Diameter Seai;ns N7ateral(top 50'1 DEpn FAer Mater3l SBalow So') (j T'!PE OF $ TIC WORK: NEW INSTALLATION A P.EFAiR ADDlT10r�I i I CESTRL'CT.O% ) INo septic sy>rem purmitted if pubi;,seweW Sv3;l2bia within Zo foot.) lcsn latfan wjl:ser.,e: aescence_ CO`hMreia'_ Other NLMber cf living units; Number of bedrooms ^� Character of soil to a depth of 3 feet; -'tea dt! avatar taDie depth SEPTIC TANK Z' Type;Mfg C�+�' P(L Capacity i;ZC c No.Compartments PKG. TPEATMENT PLT.❑ Method of Cisposa! " Distance to nearest: Well ^Oc Foundation C ' Qroperty Line p� LEACHING LINE QI No, g Longth o1 lines ' x FILTER 8=C &C 6n Tc::l lengtnJs;ze [ •��+ � O`taist3nce to ne3re-st: well ;"- Foundat•'on .f 6' �.. PrcFerty Line a SEEPAGE PITS I I Depth Sim �!7 i.f /.�r Number X SUMPS, k( Distance to nearest: Wei'�7 ra a" F;under on Te Pr r DIS�QSAL?:rNDS r7 �rtY Lute �1G'Z' ne eDy CuriPy that I have prepared this epFlication and that the work will be done in axorc3nce with San Joaquin county ordinances, star.lams, and rule;and regulatiors of Via San Joaquin Luca, Health District. Horne cwna-or liconsad agent's signature certifies the following: "I certify,that in the performance of the work fo,-whieh this permit is issued,r shalr not employ any persen in such manner as to O*zome subiect to wor-cman'S curioansa:ion Is-A'S of California."C.intractor s hiring or st b-connecting s-anatu-e certifier the follewing:"I certify the:in me pe7rforman;e of the work for Which this parmit is issued,I shall employ parsons 2rcjac1 to wont pan"s ccn.anaa• Von 131At Qs'California-" The applicant mu t all for all required inspections Complete drawing on reverse ride, S,gnec X— . T;t:a: 16 72 Date: -�� FOR DEPARTMHNT USE ONLY _ AaAlication Accepted by _1,�'e .1 qui L C' I 1-7 C Date Arya C� Pit Cr Grout Inet>detion Fy Dsm Fina!Inspection by\.�� ! ri..0 Cate` Addit:er21 comment.: ^. Stk 466-6%31 C Lodi 363-3621 ❑ Manteca 223-7104 ❑Tracy 935-15�385 � APpficant•Peturr all Cowles to: Environmental Health Permit%Services 1601 _, Hazelton Ave., P.O. Box 2009, Stk., CA 9E7_71 riAf*,UNT RUE AMOUNT It!1A;—eD t c NFC CuSH RECEIVED CY DATE Nli PER•YlT N0. EH 13.24 Iliev. EH li-2t1 Q i t•'a �l�— Jr t I/-2.0 X11