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�. APPLICATION FOR PERMIT. AN JOAQUIN LOCAL HEALTH DIST 1601 E. HAZELTON AVE., STOCKTON, CA ap Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is Mleby made to the�Ssn Joaquin Local Health District for a permit to construct antll0r install the work herein described. This application is t., maps Iri:wmplianCe with San Joscum County Ordinance No. 549 for"wage Or No. IOU for .It and the Rules and Regulations OI the San Joaquin t Local Health District. �� 23 Job A411969001c City -Sp Fie^ ✓ Lot Size PM Owner's',Neme -S�1F`l G/� Lfi/rlyA�� Address !`�o.z?o it A / fiyS7 dd �hgn•(9�6 �Z-Z//O P' /3f.�� 3663 o orsc l an G d6- l Contractor. i Address J� � �'�Fcd ! e?.4 z (Sic �'-57 TYPE OF WELL/PUMP:: License No.S/9(/26 phone 'J�j� I"� i�I NEW WELL [] WELL REPLACEMENT J DESTRUCTION Li ;• PEP.TI INSTgLLATIOh�ri /�� SYSTEM REPAIR O OTHER.I'Or Soil% ✓iyrf DISTANCE TO NEAREST; SEPTIC TANK�9""`vr'cSEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION �,�.AGRICULTURE WELL __ OTHER WELL ! INTENDED USE I- TYPE OF WELL PROBLEM AREA -- P1T5/SUMPS _ CONSTAUCTION SPECIFICATIONS ❑ Intludiiel • 4L Open Bottom IJ Manteca Dia. of Well Excavat�r( Dia. of Well Casing ,4ow.F rt Domestic/Private p O Gravel Pack 11 Tracy Type of Casing 'eG^"Q Specifications / 0"t I 1 Delta Doom of Grout seal.� � f I I Irrigation �, ZOA l .4 Type of Grout iGt�M Of] Depth I I Easwm Suribca Saul Installed by 0104s,4- Repair Work Done V Type oN Pump H.P. Well Destruction 0 Well Diameter „ 6 ' Stele Work Done Soil�,�i„7J �SGiC.S�?►�%r Depth F zo ' Scaling Material (lop 50') i Filler Material (Below Spot !4 TYPE Ofit,;SEPTIC WORK: NEW INS7ALLA TION I 1 IiEPA W.A0DIT10N I I DESTRUCTION 7 I INC aaptie syatom parmitletl it poetic sewer is p �' Installation will xrv•; available within 200 teat.) :Reatdenes_ Commercial_ Other_ s,Num : tief of living units _ Ie of bearcoms - Character of soil to depth of 3 deet: _ SEPTIC TANK I Water table tlopm C1 TYPe/Mtg Cp•citY No. Compartments i. PKG. TREATMENT PLT, C1a ,1. ,,. _,• Method of Disposal t� Distance to nearest: Well Foundation Property Line LEACHING LINE: ii rt Na. 8 Length of linea _ - a Tout long FILTER BED i7 O Distance to nearest: Wal th/dz• r ,I .—__. Foundation_ Property Uns SEEPAGE�PITS i I'I Dapthl , Sire _,- y---- SUMPS t' _ Number g; L7 Distance 10 nearest: Well_, Foundation Pro Vii _ DISPOSAL PONDS l"1 i party Line I hereby cart11Y that I have•Drapared]this application and that the work will 1 rules and:iegubhons of the San J +e Bona in accordance wdh San Joaquin County ordinances. stats bws, and �. Caputo Local Health D13trlrt. Home owner r licensed agent's signature prtrfi" the following: "I certify that in the performance of the work la which this permit u issued, I shall not employ any Person in aVth rnannar as to become cuh sCt to workman's �. tion canlfies the lawa 't iCalolmia.'! COntfY that iln the paAormance of the work for wni compensation 11 permit iss'csuetl I shallemploy p•oonsof California.,, Contractor,a lsu pct ro worxring or imen's comtynsy. The apWicant must tall fe ;all required inspections. Complete dramng on reverse side. # signsa)C �i�J/C .ifrl ti�9lmi o '.cam fI/.oraf�-- l _ Title: Date: � j 9a 1 txyr F EP NT USE ONLY - i Application iAccepted by Data _ Area L pit Or Grout InspaCLon by :, �. Final Inspection by Adnilional Comments; Date 1 O Stk 4ail-Ml ,O Lodi 369.3621 O Mantaa; 8Z-7104 O Tracy fi35-0305 ApplicantAsturn all copin to:.Environmental Health Permit/Services 1601 E. HasNlon Ave., P.O. 1301 2009. Stk., CA 85201 I '. I r y FEEAMOUNT . f INFO pUE 'AMOUNT REMITEDEN CK r RECEIVED 6y C45H PATE uIrnPERMIT NO. •.EH .2a(REV. �i i� �I 35 AI (�U / z /sem / z�ra /3y