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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA -- Telephone (209) 4666.6781 ' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Cornplete in Triplicate) work he Application is he.ebV+fade to the San Joaquin Local Health District to a Poor+t to consirucl W41of No. 1862 for wefl/punp aatal nd the Rules ad Regulations of the S n Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage ��r,/Gt`� Local Health District. ;007a }��,�..,, / �7 o �...J�-1 /G0/ C'1 /2 Chy-•�1--- Lot Sire �� - PM Job Address � / Address _ Phone �_. Owner's Name - __ter_ -�'-� �?� �A o�iTar /S,"� ►✓s 'y- a-•f 9k- Phone "!?6!3 �RaE �N�ctorAddress '. . .-..-.-:.LicenseNo._ - Ca E-OF TYPEOF WELLrPUMP. NEW WELL Ct WELL REPLACEMENT G.1 DESTRUCTION n O, - - SYSTEM REPAIR C-1 OTHER 0 PUMP INSTALLATION L] DISTANCE-TO•NEA7IEST:'SEPTIC'TANK _._.._- 'SEWER LINES ~'""_DI5POSAtr FLD.. PROP. UNE OTHER WECI PITSISUMPS �. , ` ""---''-'�--- FOUNDATION __.-_._. AGRICULTURE WEII - -- r. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ation pis.of Weg Casing D Indwtdsl O Open Bottom Q Manteca pie. o}wet Exwv-* Type of Cesin �' SpaeiFKahons 0 Donrestietpr'ivaa ❑Gravel Pack ❑Tracy Depth of Grout Seat - Type of Grout f1 Public CT Othe+ n Delta .� fY I I litigation -.Approx. Depth 1 I Eastam Su+1aEe Seal lnstaEad W r. H:P:, Stale Work Date Repair Wo=k Done 'u' Type of Purtgf - Well Devnivion 1"-, Wag Dianbla+ Saalidg Material(top 50') Depth 'Filler Material 1981OW 50'I TYREt'OF SEPTIC WORK: NEW INSTALLATION + REPAIR/ADDITION I I pESTRUC710N 1,1 [No septic systan permitted d pubec sower K I - - A is"Aable within 200 feet.) - Insagation-w.lt serve: -Residence_ Com rcial Other �_r_ _. -,-L I Number of Jiving units:—,Nurnber of bedrwoolf - 7 L^ %�a�. ..`� Water utile depth - Chptacter of sal to a depth of`feat= t7 _ M t ` _�� i ,YJB No. Companmonts SEPTIC-TANK C7"Type/Mlg if,-Medal of-O+sp - PKG�TREATMENTPLT.'L P.roperty�.le'6�---c--' I f w - Danoe-to nearest:.. ..Wag .Foundation. �! -. -•gE� 3'. Trial lengthtsire ---L-EA6HING t�NE-�-+'� --No.•Btenglhvi iirws- ' '-�-X�--- FILTER BED 0 Distance o nearest: Wog . Foundation Property Line ---.- i SEEPAGE PITS 1.lJOW It -JQ�.-Sire -, !O 1 0- +--- Number. SUMPSProperty Lir* 'Oisartce to neareri; Welt_S;¢[t_f Famda�iort �` ,` " DISPOSAL PONOS I'i ,1 hereby coney that i have prepared this apdication and that Iho work will tits done n Accordenco with San Joaquin county o+dkwnas, auto taws, and rotes and regulation of the San Joaquin Local HoaRh Oilaict. Hama owner l Icons ori agent's aoaquin certifies the IOIMwing: "I urkty that in the perfamefue of the work to which this portrit m issued, I shag nol OmpIOY any person.n such manMr as to baCOM8 WbiOCI o Wgfkfharl S re111pensalinn laws of California.-Condacla� subiect o workman's companss ns t Condlas the foeowing:"I co,Vf that in IM pedaMan lr Of the work la which this pornril is issued,l shell employ Pe tion laws of California" The applicant mus equked inspections. Complete draWinBO�� / Title: Date: -- ! Signed%. �-�'J�/Zj� FOR DEPARTMENT USE ONLY t rOate Ataa'�r�„�- EII Application Accepted by �`/ Date T'�` Final Inspoction by rteL�L-- Date I� / Pit or Grad inspection by 6( �" Additional Comments: Stk 4666781 ❑ Lodi 369.3627 O Manteca 823.7109 0 Tracy 8355386 O I 0 SjkerR- Re81 all copies to: Emntonmenal Health ParmitfSaMcas 1601 E. Hazelton Ave., P.O. Box 20M, Stk.. CA 95201 ` I` FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. ( INFO 9,q , l {��j( 1 • EH1}rEIPEV.+raUi 72 1 EH 14 26