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- L APPLICATION FOR PERMIT • �rr SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ! Telephone°(203( 466-6781 PERMIT EXPIRES I YEAR FROM DATE 13 .7ED'C�. o; /6;fjry- {Complete in Triplicate) 'D Appii-,ation is hereby made to the San }Caquin Lo^al al;h District for a permit to construct andr'or instBfY ork h des his application is triode in Compliance with San Joaquin Cou.n;} Ordinance No. E,'9 for sev:age or No. 1B£2 for well:pump and i�@' s a.n�gula f the San Joaquin Locat Health D strict. �L�CsFgl 195-280-20 Job AddressSoutheast corner McKinley Ave. & Lague city Lathrop Lot size 1 d6' acres P1i195-280-21 to southeast corner Louise Ave. & Lague Rd. r Owner's •.amesaV2 Mart S11P,1?r[Edi PtR Address P_ n- ROX 4278- Modesto CA----- Phone fi _1 95352-4278 Cortr�. or ► razor) and Assoc',ates��ress �Rfr� N. Winpry Ave- License f4o.49QgOR Phone Q 1— 7 TYPE OF NEW WELL ❑ %IVELL REPLACEIdT; � TRUC71ON I❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER $ Geotechnical ' DISTANCE TO f:EAREST: SEFTIC TANK,1 100 r SEWER LINES 501 D!SPOSt L PLD. 100' PROP. LINE 50, FOUNDATIONI 50r AGRICULTURE WELL 1001 OTHER WELL__]0W PITS/SUI,,PS 1100' IN'TE``'DED L'SE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECJFICATIONIS ❑ Industrial n,� r`' Open Sottorr4,/A C )Janieca N/A Dia. of Well Excavation r' Dia. of Well Czsing I s �V ❑ Domesiic;rnvaie ❑ Gravel Pack"' u Tracy Type of Casing N'/A Specifications N/A i Public (- Other _ f-1 Delia Depth of Grout Seal N/A Type of Grou�53Ck Sand # I l Irrigation Approx. Depth+ I I Eastern Surface Sedl Installed byKJ',a7in Ann Age of iaFAC Repair iNork Done Type cf Purnp H.P. State Work Done Y,rell Destruction C Well Diameter Sealing lv'aterial flop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permuted if public sewer is N/A 1 u avaEable within 200 feet.) lns;al!a,;otl will serve: Residence_._.! Commercial_ Other i� Number of living units: Num3er,of bedrooms Character of soil to a depth of 3 feet: ! " VVa;er ',able depth N SEPTIC TANK ❑ Type:f,4fg `� "" Capacity No. Compartments ` PKG.-TFEA T MJFNiT PLT. ❑ � Nethod of Disposal r Distance to!nearest: Well Foundation Property Line r� LEACHING LINE ❑ No. 8 Length of fines Total length:sire I •rte FIL T ER BED ❑ Distance to nr8arest: Well Foundation Property Line j SEEPAGE P17S I I Depth Size Number SUMPS 0 Distance to ifearest: Well Foundation Property Line � MS?OSAL PONDS ❑ 1 I hereby cenify that I have prepared this aApfication and that the work .,:ill be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San Joaquin Local Hea!th Disirict. Home owner or licensed agent's signature certifies the following: "I certify'that in the performance of the work for which this permit is issued, I shall employ any person in such manner as to becorne subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature-_ } certifies the foliowing: "I ceni`y that in the performance of the work for which this permit is issued. I shall employ persons subject io workman's compensa- tion lavas of California." The applicant call for all re ',red inspections. Compieie drawing on reverse side, Signed X Title: Dro; Date: [Q r R DEPARTIAENT USE ONLY Appficc'io,n Ac.eptEd by Date �" r Pit or-G•out ics;eCtion Y -` Do',e _ /Final lnsaec:ion by D2-e/6 ❑ SA =5P-5761 r^ !I Tracy F_35-£i r,�, lice^.t =E:urn all p es :o. �nvircnr en,al He01:h Perm 5 t•in ( ces 15A E. Ha.el;on Ave,,A.veP.O. ..cx 20..3, c_:k., CA _oc..2.,1 ,rJ !! T x!l.7L :T 'r.E K4�} F.ECEr\'ED Ey r`E PEF.II,IT'!�D. f � I: