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.• Z APPLICATION FOR PERMIT SAH JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE,-TON AVE., STOCKTON, CA Telophone (209) 466.6781 PERMIT EXPIRES : YEAR FROM DATE ISSUED (CornFlaite in Triplicate) Application Is hereby nude to the San Joaquin Local Health District for a permit to construct and/or in"the work itareln Ascribed•This appf-dM it made in compliance with Sen Joaquin County Ordinance No.549 for sewage or No.1982 for well/pump and tha Rules and Repals"m of the SMT Joagldn F Local Hearth District.. Job Address X71-- - City Lot SIM PM— Owner's kerne r _ Addresu ��~ Address Qcense No. �— Contractor - — TYPE OF WELL/PUMP: NEW WELL ❑ WELL RFrr- CEMENT DESTRUCTION C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE:W'cR LINES DISPOSAL FLD. PROP.LINE FOUNDATION AGRICULTURE WELL OTHER WELL-241' PITSlSUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v ❑InckW.1 l ClOpen Bottom ❑ Manteca Dia.of Weft Excavation_fir. _ Dia.or Wall Caslrhg �.Da+hestic/"rivets T�Gnrval Pact QS Tracy Type cf Casing-- �' - Spoeffical"°As ❑PvWic Ll Other CJDelta Depth of Grout Seal ) TM of r` 0 1;wt;on --Approx. Depth ❑ Eastern Surface+Seal Installed by Rspak Work Done O Type of Pump H.P. State Work Dons WOR Destruction. ❑ Well Diameter Sealing Materiri{top 50 1 Depth Filler Material IBelow 50) TY "OF Sble within 200 fam.) EPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION G DESTRUCTION❑ (mom > K R t Installation Residence — Commercial— Other Number of living units: Number of bedrooms Water table depth Character of sob to a depth of 3 feet: Capacity No.Copartments SEPTIC TANK ❑ Type/Mfg mMethod Of Oisposai PKG..TRFATMENT PLT.C Property Line Distance to nearest. Well Four LEACHING LINE ❑ No.a Length Lif lines>—_ Total length/e+z y� FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line— Number SEEPAGE PITS ❑ Depth `Size . SUMPS ❑ Dinos to nearest: Well Foundation Property Lina rta DISPOSAL PONDS O _ i hereby extfY that I have Pxepored this oppt"tion and that the work wifl be done in accordance with San Joequfn Bounty xdinsnoea.stat'laws and, w reales and regulations of the San Joaquin Local Has"District. Home owner a licensed agent's signature car I lies the following:"I certify that In the performance of the work for which tfhk permit k issued,t_shd not erthDkrY any prawn in such manner as to become subject to workman's eornpnnsation laws of Capfornia:'Convaetor'a hirirhp or ar6 corttrectln0 algn�+re csrtlfisa the following:"1 certify that In the performance of the work for which thh pemhit is hewed,1 NhaR employ DMsors srrb;stt in workrthsn'a conipMua- tion laws of C 00MAa." The applicant mup CaR for an requ .Complete rewi on rse side. Sigma Title: Dere: R OF�ARTMENT U NLY '/ Application Accepted Accepted by ate —9,2( Ann Y d A09 It ��Final{ Daft Nor Gran Inspection oY Date nW�tO^by It AddkkxW Convtsnis: ❑Stk 498 781 ❑Lodi 3W3821 ❑Manteca 823-7104 ❑Tracy 8564M to: Envionnhsrhtal Heath Ps Services 1801 E. Hazelm Ave.. P.O.Box 2008,Stk.,CA 86201 Applicant-Return an copies a r t EWFO AMOUNT WENT REMrTTED N FEE illy DATE PEAI1pYN0. Y BI 13,24 IREV.r/sei .. CH W2a r r d.w.�[j�..rJ.`i a .f.!•_,�'! i"�� S.c°.'�..i fi., .Ji..t...-.. J. - ... _c .. .- v�i�' . ..'`+..'.p .