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kSrT� - <r 5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1661 E. FIAZELTON AVE., STOCKTON, CA ry Telephone 12091 4666781 A, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (CompF,to •n 7nplicatel ant natle orenmpfiun[o nection is wl1 Sun the Joapub Cases Ont nendu Na."'J Inheilth t an y.,.torr Noll r)1062101 wand/or pump end me Rules and turner Regu Regulations of to Son Joan n r Local Iloailb Our""- City "y Lot SRR a[_ -1uL' --- PM._�-- xT' - Job Ann exsPhone J _. _�r O Addnrss Ownei a Name Address_ LicensPhen e No. ___— C ' Convaclor___.__— NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O TYPE OF WELL/PUMP: SYSTEM REPAIR-❑ OTHER ❑ $ -- PUMP N:STALLATION ❑ DISPOSAL FLD.___PROP.LINE _ k SEWER I NES p1T5/SUMP �,J DISTANC_E TO NEAREST: SEP FIC TANK _ —_ AU—rc�,L7UF E WELL _OTHER WELL FOUNDATION _ _. INTENDED USE TYPE OF WELL PROBLEM ARf.A CONSTRUCTION SPECIFICATIONS Dia.of Well Casing ❑Open Bottom f7 Manwca Din.of wen Escavaaron CI Indusu al Specifications _ a ❑Gressel Pack n Tracy TypeDept of Casing ' fl Domestic/Private Depth pit Gmul Seal _ _-- TYW of Grout__—.—�--- t ? 1'I Pubbc 17 011ier Il Delta - _Apptoa. Depth I I Easlom Spdacu Suul Insllled by - I I Initiation -- H.P. State Wolk Desire Repae Work Done r Type of Pump Seating Material(top 5D'1 Well Desirun on f] Wall Diamorer ---^ Filler Malelial IBabw 50) --- —"-- "' a Depth U I YPL OF$EPEIG WD11K: NEW WSTAI CATION I REPAIRiADDITION 14' DESIRU(:TIDN ravalable wub,R 200 feet la,l I rvAtc ewer ' f+Y% �� Commercial_ Orrmr_ i$ Installer on will sc e' ftnAdence_— J _ M1 Numbrt of Irvi 9 uniu Numner of 1,1 oma Water table depth- Chasers( amh_�? Sep Chancrs(of-.it to a depth of 3 leen r pm—_ Capaa ly�. -- No.Compartments -- :� SEPTIC TANK ❑ Type.r 0619 G.yJjl_Q Method of D'ISPOs l rt• PKG.TREATMENT PLT.fl 117L/ Clarence to nearest. Wen CS�_ Foundation_/J-- ProlwnV Line 0 7� -/ _ Total lon9th/siza_z LEACHING LINE Y-r Np.8 Length of Inas—.- �-1=b- : PropenY Line 4, S Cl Distance In nearest' ^Wall Foundation__-- FILTER BED �I ' _ N mbar {" t SEEPAGE PITS 11 Depth __ — S rn p pre,Iy Line re ` el SUMPS. ye,Distance wraesr W �><� elL�..LUFD ddon: t 2•L/(116 ,s' DISPOSAL PONDS I:7 t od ace stat la d r p I,also,Caddy Ibe,I basso prepared U e applicat o and that Te•v0rk w 11 be done n.rcco tlano 1 5 n Jnap c V '."rules end regulations of the Sen Joaquin Local Health D sv cr. .I tend that n the podonn eco of the ork 1 ti h this perm t s'ssued.g s halet. n LL t Home owner or licensed agentb signature certifies the lon Painp Y B y p p s sun cr tD workman a co pre a t employ any ousels in ouch manner as to become soma I work e s cOmpensauon laws of Cul to nm Conten s Rising or sutrconuan n g yP) candies Bu lollow n 'I easily that in the podormanee of New k 1 we eh IM1rs emit rs usual I shall am ley person le tion laws of California` The applicant st call for all required inspection Compote draw ng on reverse side, I� /11LG.c'LLci'l. Dale: 7-- Sian FOR DEPARTMENT USE ONLYP Date.�'�� Area ~/ l L AOpliceripP Accepted by y1Av`-r C U Des m Delo Final ipaction b P I or Grout Inape.t un by _ CY . Additional Com las Tmcy 635-6385 ' ❑ Slk 466 6781 ❑ Lad 3 7621 ❑M^arae 623 ices O P 0. Bax 2009, Stk., CA 95:01 ApDlicem Return ell copies m Envi,Cnmamal Health Jermll/Services I6L'1 E Hazelton Ave., nY itv! I fEE AMOUNT DUE AMOUNT REMITTED RECEIVED BYFan GATE PEPMIINO. Nf0 I d U D S u w. *i RINI k � .j.:• ,.'w Pm sa�s:`§¢loss h4,x,':;`".+Csn..;r `a'•1 1. _ :ii9, i6fte N' '&in**_'�h•A'-fd.�.�'.AF!.+' .. ��'I;.�.ak�,w+�'.E, i/;v�.3.yc'tP"a+i'i ;.