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APPLICATION FOR PERMIT I' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA7.ELTON AVE.. STOCKTON. CA YM ENT T elephone (2091 466 6781 C I V E D PERMIT EXPIRES T YEAR FROM DATE ISSUED ,'.UG (Complete in Triplicate) Ip1 X11 p(� - i Appouatum ie Nnehy made to the San Joaeum Local Health Debut for a P^Intl to Wnslru"and/m in 11�IrVhN hfw,1,{♦yQ•, -Inn Sir. J Q,is (7(.yL icon Junnu.n made m snmpkan�x with San Jo.r9um County Cub"ncn Nu.!A91a sewapn a Nu IRE)Ia ws•Ilrprmp ion l TIv-4111 M(gIMTLIt,.'+ACES _ t 1111al II1.11IM1 ItulncL �a./� City4Oy /-- LM S:.e IrACA_rr— PM Jon Address 0. ,'Ownei s Nauru .SJ�III O//3.M + Addressho e ..J.a.Qi e�Das__�f..��/arlhLr�(�Ip. Pnx /fy Conti.cta i/rrf�esal.�—AddnessrHal+��a�.lgaaM-�'I�M_Licenxe No.trVJ./��Pnonr�ltrt�.r767� T'IPE OF WELL/PUMPNEW WELL (I WELL NEPLACEMINI I i DESTRUCIION 1 I PUMP INSTALLATION I1 SYSTEM REPAIR I1 OTdfR x r0lolr r/ DISTANCE TO NEAREST: SEPTIC TANK _N/ii_ SEWER LINES _�.-Z��— DISPOSAL FLD.l PROP. LINE <s� FOUNDATION <�Y�. AGRICULTUPE WELL .N A_ OTHER WELL_. — PITS/SUMPS asr/'/ — _ _ _ __- - /— .__.�—____.._. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPFCIFICATIONS industrial Ll Open Rottom 1.1 Manteca Ow.of Wea Excavation_.� Dia.of WeR Casmg _ 1 I Dournstic/Private 1.1 Gravel Pack I1 Tracy Type of CaslrNl—J�//►AFl/ _ Specifications �.-1.��. 1'I Public fl Other Il Delta Depth of Grout Seal p17�� _ Type W Grout AIVOW) • 131141114 1 1 hrgaton ._. Allen. Depth I I Eastern SOdaca Sisal IbstsIllW try —__----- Repair Work DOM I1 Type of Pump _a✓/it N.P. n_ Sete Wa4 one m1tM Well Destruction Ll Well Diaeter Sealing Material 50.1 6&&-A ADq Depth Filler Material IBRIow 50.1 TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 Marseille:syslam pee ubul d public sower,as O awdahle within 700fast.1 Installation will semm rve: Residence_ Commercial— Other_ Number of Lwne units: _ s'...:erer o/bedrooms Character of soil to a depth of 3 feel: _._Water table depth SEPTIC TANK Ll Type/Mlg Capecity. _ No. Comparunents PKG.TREATMENT PLT.Ll Marriott of Drs, l _ Distence to nearest: Wen Foundation Property Line - LEACHING LINE LI No.B Length of IIMa Total length/see .. -.---- 1 FILTER DED f I Distance to reauese Well_ Foundation Propene Line _ SEEPAGE PITS 1 I Depth Sue_ Number — RUMPS LI Distance to mall Wen_ Foundation . shorteM Line DISPOSAL PONOS 1 1 1 hereby comfy that I have oropaled this application and That the work will be done in accordance with San.loaeuin county ordinances, slate Ww•, and a, rules and regulations o'the San Joayum Local Health DBtnct. Home owner or licensed agent's signature canities IM fonowing: "I cenity that in the performance of the swak for which this petrel is issued,I shall nn• empiny any overact in such manner as to become sublecl to workman's compensation laws of CablorNa."Contractor's here or tub continuing sgnalae combos the following:"I cattily that in the M'formance of the work lot which this permit is issued.1 shah employ Persons subpart to wordian s eompoe' Tion laws of California." The anp/lliccant must call for all lfcufaij/edlmop/ey'onns. Complete drawing onn rswarm side. / Title:_VP/tafs Oaro: _i/yw D ENT USE ONLY Application Accepted by - ! Date Pit or Grout Inspection by Date Final Inspection b/ 11 mOats u � � Additional Converters: �fet"�!Q IJ SII, 466 6781 ❑Lodi 369-3621 0 Manteca--'Q3-710k C Tasty 835-6185 Appy.arl-Return all copies to: Eny.ronmentel Health Permit/Services 1601 E.Heaelton Ave.. P.O.Boa 2009. Stk.,CA 95201 FTE AMOUNT DUE AMOUNT RkMITTED RECEIVED By DATE PERMIT No. INTO IFF �. 3 �y: 1 l�