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r' II 1 M11,10ji5ill if,151R111till � 4 ��-r w+•� APPLICATION FOR PERMIT oY I 1vA CAN JOACUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephono 12091 46&47&1 q4 js�Z4 Tl AMIT'EXNIRES.•i•YEA#i•FF#0M OAgTE ISSUIa0: �•• IComplele in'Trihlicatey Application is hareby,made to the San Joaquin Local Haallh District for a permit to construct and/or Install the work herein dascriWd.Thi;application is made in compfianeo wit-I San Joaquin County Ordinanca No.649 lot sawrpn or No.1862 to wellipump and the Rules and Ragutatlons of the San Jaaqu:n Local Health District. t Job Address // P City ( Lot Size 12-1 k 1 k"i PM Owner's Name vJdwsst1 l C_ i1.�a�\fie Phone - 'il•� 4� �as+r^+ry�T s 4 Contractor SN Addless Sa A—L-W•n"gi License No. p1 C 3�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER If( DISTANCE TO NEAREST* SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE FOUNDATION_ _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIfICATiONS ❑Industrial ❑Open Bottom ❑Manteca Dia.of Woll Excavation D-,:,of Well Casing ❑Domestic/private ❑Gravat Pack 0 Tracy Type of Casing Speaificatiane ' ❑Public rl Other n Delta Depth of Grout Seat Type of Grout I I Irrigation —.Approx.Depth I I Eastern Surfara Seal Insialfad by Repair Work Dong ❑ Type of Pump H.P. State Work Done -.-Will Destruction ❑ Wall Diameter Saaling Material Itap 50'1 Depth filler Material IBotow 60.1 r+ TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION I I DESTRUCTION I I (No sapfic system parryAted it public aewei Is �] available within 200 feet.) Instatlatan will serve: Residence— Cornntercial_ Other Number Gf frrirtg units: Number at bedrooms _i v.+ C htiraGter oI soil to a depth of 3 last: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments _ PKG.TREATMENT PLT.❑ Method of Disposal ' •, Distance to nearest: Well Foundation Property Una. LEAC'm4ai LINE ❑ No.;Length of lines_ _ Total length/site i .r FILTER BED ❑ Distant.,;to nearest: Well Foundation Property fine SEEPAbiE PITS I I Depth _.�. Size Number" # SUMPS ' Ll Distance to neatest: Walt Foundation Property Line diSPOSALRONbS, a= I h6jjhy;clrtilyr that I hp prepared this apttication and that the work"be done in accordance with Ssn Jeaeiu&county bi it wiieaa,itYa laws,ind nilss artlf rUIalions of the San Joaquin Local Health Dahirt. Hwtii r„`alar«liunsed.agent's signature certifies the following:"1 pr°J1y that M the perfoimanea of*fie work for vvhhich this panni!fe Isugd,I shag not sn ”' in such as ta.bscoma wbj�ct to tvorkrtrart's tampansatlan.lavw at Cilifcrnia."C«*rations hki w all comae . iiW si' y �Per's«! Riariner. tEnD.s+G!sa.. csrtHlea Ili.fplo+wfnp:"I rectify that in{ha pskoiriiinca of the work lir which this permit Ii Mused,I"If ample¢pilins sib f to vroiktnen's t art+Penaa- 10i liars ref dufoinla." The aZiptle:f f Init c's,161w2iirequ6soding Compbje dnaanp nevose Slpite'd jr� �r" Tltie: !r� ►�,�1[c!�f T7�— Date:_l �yn � FOR DEPARTMENT USE ONLY App;ri.:tisit Ariciptid�y 5.-w�- �,R ., trot rw Oats IZ. V r,i oa Pk ei(iiofii liuplctinn by Data Frriat lrispeetian by Date AdditloriiI Comments: - ❑Sik 46j4T\f ❑Lodi 309.3621 ❑Manteca 823.7104 ❑Tracy *1354LVS Aii�qc iii=Utvit A cbpiea to;invironmeniat Healili Pernilt/Services 1601 E.Hazalton Ave,;P.O.aox 204§,Sig.,CA 852d1 FEE INFO AMOUNT DUE AMOUNT ftEMtTTREMITTEDK RECEIVER BY *]ATE P[AMIT'N17. •EH1}ilitilV.traar EN 13.S.a a141..