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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete In Triplicate) Appbcatma is hereby made to the Sen Joeoum Local Health District for a perms to construct End/of vision lha work herein described!. This exploration s made in compliance whh San Joanum County Ordinance No.649 for uwago or No.1962 for y.11, tamp and the Rules and Regulations of the Sen Joaerm LOON Health nsuct. Jab Address /rlitwyI 99 City s rRA/ Lot Sin /95'x s 94 PM Owner's Nome .SI�PXmlJ aAPs{Hf/3TR.Ca/ Address .lfet/L.Q/�CIJY/s�IIy_ST1lea/ Phone e e2 7 7 yJ/-i/o/ Con laclor f1.01/1F1K.�la1@OJ) Address_7_JV�/4&4eiLAfiA= ,✓6 License No. 40<j4_. Phots TYPE OF WEIUPUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ll SYSTEM REPAIR 0 OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION _AGRICULTURE WELL -._ OTHER WELL PITS/SUMPS _ F INTENDED USE_ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ CI ItttnttiN ❑Open 8ettom ❑MdanteCE Du,of Wall Enuefbn Ds.of Well Caslnp _ fl Domestic/Pdven Cl GrakN Perk ❑Tracy Typo of CeneW Specifications 1'1 Public Il Other fT Delta Depth of Grout SeH Type of Grout__-__ l NrkMlgn —Approx.Depth I I Eastern Sudan Seal Installed by _ Repair Work Dona ❑ Type of Pump H.P._ Sun Work Dela _ O Well Destruction ❑ WON Diameter _ Seat?ng Materiel Ilop S0'1 _ Depth Flier Material 18ebw 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I 1 (No fepllr&v.wm tW X public savers r\ as vaitl+tn200 1 Installation will serve: Residence__ Commercial,- Other n Number of living units:_j9_ er Numbof bedroons Character of MR to a depth of 3 feet_QJ Ay Water table dept _ SEPTIC TANK ❑ Type/Mfg &Y"17-1"46_ Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Onposer Oweari to nearest Well F-oeWatlnn Property Lin LEACHING LINE UK No,•Length of lines-_.4-70 0 ,1Z&i /-.Ex Toth FILTER BED ❑ Distance to ntemt: Wall�_ Foundation SD" Property Lin _ VVAGRy SEEPAGE PITS Depth AS' _Slee Number / SUMPS L1 Distance to neroat: Wel /10 , Foundation_(Eta ' Property Low_Jw' DISPOSAL PONDS ❑ SKkcr Ly 1 hereby cantly tat 1 have pleased this applictin0h and that the wall wW be done in accordance with Sar.Joaaum canny ordinance,ante 446, ale rules and regulations of the San Joanuln Local Health D(7tricl. Han ow r m licensed agent',signature consles the following:"I censY that In Cie performance of the wont for vmich this permit s issued.I share ret employ any parson in such manor as to become subject to vrorknnn's comwnsefion:sora of Csliforri s.'Contracror's hike or sub-contracting signanuts coniosis the following:"I ith"that m the performsncn of the Milt fa Which this permit is neutral,1 short employ pan zie subject to workman's ConlpenL tion lave of California." The applicant must can for an required insgctbns. Complaw drawing rvi reverse.yside, slglne ZfEle—QAE //l_cv�._-- enc_�iy� Dm: FOR DEPARTMENT USE ONLY Application Accepted s s \ PP ell b Y Data_ Arae or Gran Inspection DY --- Data_ Final Inspxtlon DY u&&I' .— Dan_l 9 ,tical Comments: _ L ..tk 48"781 ❑Led 309-3621 ❑ Menace 923.7104 ❑Tracy M41786 Applicant- Return an copies to: Environmental Health Pormll/Somicas 1601 E. Harallm A".. P.O.go.2000, Stil CA 9=1 NFO /; OLUNT Dl IF AMOUNT REMITTEp O Ntr/` /R/fF/C�Fa.�VEp eY p/TE, faro=Reg. "//y1111 JJJ� 111N i,�si S N (/ I / Q 'L�/T //// • /�/ _ 1 IT— i