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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT itw11 E HAZEL ON AVE., STOCKTON, CA Toli-phone (209) 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Con)plete in Triplicattt) ,- I. •r!Hr•,,�!tr f�r�t,•rt for f errant tit cnnstnrrt and'(11 111sta11 the work herein described. This aPpl'rnturn Is Al•{L,i.,rtv.n 5 hrn+hv rn,.d••tr.lhr ;l,r I. r.1'1 Inr sew,,pe or Nn 1Hh1 for wt-Il pump and the Rules anti itellul.ttuins of Ih0 San.ndquut nanlp rat.r .•.,,IaPn e wNl+.`•to I,••r.' . L ut al I Ir,llth It fl ty � C y_ PA,� l Size Jab Ad:,re5s `-- y i� ✓�. - — - ----- Fhone YG_ — 2- 0 Owner's Name �L�(( 7 -/� !L'Js) _Phone j - Conhar.tm p'1�2, r�/h __ DESTRUCTION t 1 TYPE OF WELL;PLINI NLVV W .L ELL REPL CEMENT :. . t SY EM REPAIR i ! OTHER 11 PUh1P INSTAI l ATION SEWER LI E -- DISPOSAL FL D..--____ PROP. LINE DISTANCE TO NEATEST SEPTIC 11O OTHER WELL---.-- PITS/SUMPS l,GRICUL E WELL - - FOl1NDATION - - -- --- TYPE OF WFII PROBLEM ARE CONSTRUCTION SPECIFICATIONS INTENDED USE - - - - - - -_--- I Often Bottum Manl ,:a Dia. o'Well Excavation -- ---- Dia. of W^II Casing ! Indastnal I $peul:catrons Gravel Pack Tracy Type of Casing ...____ ` I 1 DomesucrPnva:c , ' Typo of Grout I I Other I Delta Depth of Trout Seal 1 I I I IrnflalNtn i --- A ink [)eplh Las in Snrlaie Sed,installed by -- -- -- -- sole work Done__.._____._-------------- Repair Work Done i 1 Type of Pump H.P.- - - --- Well Destruction Well O•ameter _ _ Sealing Material(top 50'1 - Depth —� Filler Material(Below 5(11 _--- -- - _ - - IYPE OF SEPTIC WORK N[W INS1Al/1AT10N I HFPAIRIADDI r�N�I I 5TRLICTION 1 IN lal>Iit within 200 feet.)s1plic. am permitted i[public sow/s will serve' NesiAenct Y Commercial Other ___! S n ✓,��f Installation 3 YJft�O� Number of living u':ds: ___ _ Number of bedrooms &��Z \Vater to a depthCharacter of antl to s depth n1 3 lent: ._� � ��- No.Comparttner is --- I ! TypelMfg Ctpacity_ SEPTIC TANK Method o Df" PKG TRFATMFNT Pl.l 1 1 Distance lu ru•arcac Well �, `' Pio;,eny Lim 3�- -----------•--- � �� _ Total length/size_ --- LEACHING LINE l I No.6 Length of lines .- �^ 7� — property Line FILTER BED (1 Distance to nearest: Well 1[- Fo ndation.�v Z J^ ^ — - Site - SEEPAGE PITS I I Depth - - - — Property SUMPS I I Disian.-a to ne rest: Well . IDV- foundation_._.j7Q- 1-lite DISPOSAL PONDS I I hereby certify that I have Ptepated rh,s aVVhLallon and that the work will be dune in accordance with San Jnsquin county ordinances, stale laws, an rules and regulations of the San Joaquin Local Heaah 013trict. permit is Issued. I shall not Home owner or licensed agent's signature certifies the following:"I certify that m the pedorrnar.ce of the work for which this ernplcy any pnrsan in sunt manner as In hncnme suhprot to workman's compensatto Aws of California."Contractor's hiring or sub contracting signature certifies the following "I ceit ly that In Ihn pnrlorman;e of the work for which this permit is issi.ed,1$hull employ persons subject to workmen's r ompensa tion laws Of California" The applicant 1 cell lot sit� nil rn%g rnnn (:impla IF drawing on reverse side. 2 signed X d/tl'� . T!'�(►jTiT _ Ttln Date: -_- /- FOR DEPARTMENT USE ONLY !' Area _. �-- — Date_ -- — Application Accrpled by -_._ _ _ _-- __. _ ✓ Date ✓ `"t Pit or Grout Inspection by ..--- -.- ---- Date//._—..__'-- -'Final Inspection by Additional Commonti.. _. t'� }L I L 1 1 Slk 466 6781 !1 Lrx1, ".71 � Mentees 827.7100 ❑Tracy 8358385 �.�/-1' -Kq'1 App'icant Retun:11!rop,ns to f nv ronnu•ntel t!oal:h Parmit/$emcas 1001 E. Hazelton Ave.. P.O. Boa 7[X)9, k.,CA yr201 _ — Fit ECEIVED By GATE PERMIT NO. ill- --AligI.RJI pl!I AM,11;NT fit MITTEO . fN 13"ta,Y t - fN -._.—