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�J APPLICATION FOR PERMIT�� SAN JOAQUIN LOCAL HEALTH DISTRICT ^ \� 1601 E. HAZELTON AVE.. STOCKTON. CA Telephone (209) 466-6781 _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 2 9 193 (Complete in Triplicate) Application is hereby,made to the San Joaquin Local Health District for a permit to construct and/or install the r"fROMENTIA}L..atuePe�ai�ahon is made in compliance with San Joaquin County Ordinancu No.549 for sewage or No 1d621or well pump antl•he if to-sa MAW,S�YTyuv�an Joagmn Local Heai!h DntripL FG �O�.jC.2S-(p-�-1144f —IF-'� Citv/�ej�.H{s+/v-ol Sire PM Job Redress A �,.j� (/� �A /J �II�&�A/V f�f`� Address ��.(ai-a-E�-/�nr• 7T Phone Owner's Name WWW" Contractor P Address � License Nos,2127 _Phone TYPE OF)YELL/PUMP: NEW WELL 4,✓ WELL REPLACEh1ENT ,7 DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR i) OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES � 'f'QDISPOSAL NLD._ PROP. LINT: / FOUNDATION _ AGRICULTURE_WELL OTHER WELL PITS/SUMPS 62) IN DED USE TVP OF WELL PROM EM AREA CONSTRUCTION SPECIFICA�N 41ineustriD Open Bottum I i Manteca Dia.of Well Excavat� y^_ 1Q� Dia.of Well Casing w al Cl Dornestie/Private ❑ Gravel Pack 11 Tracy Type o1 Casing_ Specifications as y._/- . - I'!Puhhc i' Other Della Depth of Grout Seal T ype o1 Grout.2-/-O-/— Inigution .-- A:11110.. Der, astarn Surface Suet Insleand by - Repair Work Done 11 Type of Pump n l/ H.P.—_/D—. -- State Work Done _ Well Destmcnan . . Well Diameter _- VLAI Sealing Material(lop bl)'1 --- — - Depth Filler Malerlal f0elow 50'1 y Tvl'E Of SEPTIC WORK. NEW INST AI CATION 1 I HE'PTR/AODIIION i I DESTOLICTION i 1 vllilan� frm ,ed t pup6c sewer is aaabewd � �tl v ' Instaflation will serve: Residence- _ Commercial— Other—.----- -- , . N" Number of living units- _ Number of bed1OO1S___— Water table depth Character of soil to a depth of 3 feet: ------ --- C TANK 11 Tvpe/Mfg _-_-_____.----- Capacity--- No.Compartments SEPTI PEG. C TANK PLT.I: Method of Disposal Distance to nearest Well— Foundation __-- Propeny Line_— n LEACHING LINE --- I No. 6 Length of lines -— - _—---------- Total length/silo (; FILTER BED I I Distance tp mvinst. Well _____ Foundation _._. .___ Propeny Line__— SEEPAGE PITS Dapth . ._—Stn .___--_ .. -_. Number R, SUMPS I Distant.. m nexcisB Well -._____ Foundabnn __. _ _ .— Propeny LineDISPOSAL PONDS I Neebv'-entry that I have pieturW thn application and that the work will be done 1,1.ccurdaaoe with San Joaquin county ordinances,state lawn, and rules and reguleb.ns of the Sen Joagmn Lucal Health Divimt. Home owner or bcensed agsnt s signature cenrlms the following:"1 can that in on PerformancefCalif of the C went Mr which this permit is issued. I shell not employ any person in such manner as tp become subject to workman's compensation laws of ed,I shall Contractor's s subj c so workman's c signature Centres the folk.wing."I cteety that in the Erenormance of the work for which this pbrn•rt n nsuad,I shall employ persons sublet.)to wodman'a compensa lion lam of Ca'.iform, The apperant! call for al reqSigned X . s coons Complete d©wing onlyversn s Jn Date: _ .L�— - lit./ ` OR DEPARTMENT USE ONLY -�/ -_--- _— Area Ul fiA I¢apon Acceptedby --1 Jl� _ _- ---- - -- Oale 1_-_ _ - ja„tt Final Inspection byData r Insoec ion Dy 4 twins - i ' ]A t R 781 _. Lodi nv,, 1 da Perm Str 71G Tie 935Ave . Stk., C 95701 ;.pplkant � Re,nn all copies to: Envnormentel Health Pnrm.t/Services liAl E. Hnmlton ve . P.O. Dox 7009. FEE AMOUN70UE ?Vilw FF!ti TtkD KaREC[IVFp ffATENO. CCl]]a INET l /l - fn taM L__