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f P ApPLiCATiON FO PE +�WWII SAN JOAQUIN LOCAL HEALT1f 1601 E. HAZEL T UN AVE_ STOCKTuiJ, CA Tereph,xie +2(A} 466.6781' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED — Ir-DmNlate in Triplicate} 6000 gpplicatior is trlsby madr,to the San Joaquin Locat Heahh Dist,rct for a permit to constrvct andlor install the work herein described.This appligation is .�! n,ade in cornWir•1ce with San Jgsquin County Or[iinlnce hu,549 for sewage or Ho l$fi2 for yell/pump and rhe Autos ice'?.yrr[ciiona of!he Sen Joaquin o- Local Health District. Job Addre:tsr- - i = - — CIM,• _ Q Lot Size PM n -�+r{ .flddresa Phone owner's Name _� Jfw dress cense No. Phone t Contractor f. TYPE OF WELLlPU P; NEW W LL 17_ WELL REPLACEMENT EIDESTRUC7fUN ❑ j "s SIS PUMP INSTALLATION is SYSTEM REPAIR ❑ OI HEfY ❑ 1.i«_rz. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PF!?P. LINE FQUNDATIQ,v AGftrCULTtfRE WELL OTHER WELL PIT5lSUMPS _ _ _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casin t ❑ Industrial. L7 Open Bottom. ❑ Manieca Dia.of Well FKcavation fl 71 Domestic I Private 0 Gravel Pack ❑ Fracy Type of Casing— Specifications C Public ❑Other ❑ Onite Depth of Grout Seal -_ Type:uT Grout :+ i } G Irrigation -,_/,pproa. Oapth ❑ Eastern Surface Seal Insialled by--- Repair y--Repair Work Done ❑ Tvpe of Pump H.P. _ State Work Dona_ Well Destruction C7 Well D;xmeter Sealing PAatarial atop 50'1 Depth .' F"iilar Material igelow Be') TYPE OF SEPTIC WORK: NEW INSTALLATION -REPAIR/ADDITION-U -OFSTRUi:TiOM1:k3-{No septia system'pqnnittod it public sewer r , available Within 7.00 feet.) Installation will serve: F.os;dencek__,� Commercial _. Other _ - Number of living ands: � Number of bedrooms Character of sail to a dept:of 3 feet:- _-- --Water'able depth _ Capacity Q— No.Compartments I, SEPTIC TANK ❑ 7y>e/Mfg - f I PKG.TREATMENT PLT.,_it Mathdd of Disposal _. f F Distance to nearest' foundation Property Una _ _ a LEACHING LINE '• _Al No. &Length of lines Total lengthlsiza_� •- r FILTER BED O Distance to nearest: JJell Foundat o ?roperty One _- i 4 $8tPAGc PITS ,' Depth Or --Sart. ___ Number -- SUMPS I- Distance to nearest: Foundation�J ProportV Line DISPOSAL PONDS r_1 -- 1 hereby certify that I have prepared this application and that the,work wilt 4e-dona in an,arda'+re with San,Joequin coun7y ordinances,state taws, and ; ruins and regulations of the San Joaquin Local Health District. - - i Hnn,e Owner or Kcon.wd agent's signature tarrtifi,s the lnllowing:"1 certify that in the yArfCrmanCt,of the work fpr which this permit is issued,I shall not GCOnlracling sign8[ura employ any person in 9uCh manner as to becume sut:iPC[t- workman's mi mpensation taws of California."Contractors hiring or sU certifies the following:"f certify that in Ike parinrrnance of the work for which ihie,permit is issued,I shalt employ persons subject to wnrkman's compensa- - tion laws of California." ' The applicant must ca11 for_[311 raquiroo inspections. Complete drawinp,tN1 revBrGe side. , - r.- Date/ i 'title; -Y--------_•—.�- —�-:__ l I - FDR DFPAP.TMEN'f MSE ONLY � C 7 oars. y f- // _ -•f,, Fknal In 5P,!Ct�rr:,by.. i..__.-_=---'- 5 Fires Growl Ins:�r4E�on by .f`.--L/--0`?C. I_. I �]--" /f Additional i. tk 4E6-6781 i-' LOT 36.?-:l&i1 'i=, Mpea 2999, SIk., CA?52[}1 nn'eca 823-719a {..i Tracy 83b&38S �. . ADs.nr . Return all copies to: Environmontal Health Parrnit/Sarvicos 1b0l E. Hnrelton Av'I" P.O. ..�•---. -[ - AMOL^7 14F.WTiED CK RECEIVto BY DATE Pffl MPi'Nl7 fF AMtiVtJT pU_ CASrI-�__—._- i _