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APPLICATION FOR PERMIT SAN JOAkQ11 IN LOCAL HEALTH DISTRICT 1601 E. HAZEL-ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) AppNr.inion i�,,hereby made"the San Joaquin Local Health Oisttic#for a permit to comtruc#anMor install the work herelrr described. This apollcatlon is made in complionca with San Joaquin County Ordinance No. 549 far aewaga OF No. 1862%F well}pump 9nd the Rule%$nd Regulatiprry of the$an joaqu;n Lmal Hoalth Diisrtrict_ } r J0 Address l., '• - W11/V City iiot $ixe 5 s PM - # Owner's Name r r Addre&5 Phone Contractor's Name TYPE OF WELLJPUMP;_ NEW WELL ❑ WELL REPLACEMENT L]'f '-O3TRUGTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑,' OTHEft n DISTANCE TO NEAREST: $EPTIC TANK _ SEWFA JONES �^ DI-SPOSAL FLQ_ PROP_ LINE � —F41JNDATION.. AGRICULTiM WELL I}THER WELL PITS/RUMPS JMTENDED USE TYPE= OF WELL PR03LEMAREA CONSTRUCTION SFACINC,ATIGNS -D Ir dustflai ❑ Oriah,oewm 0 Manteca :Cfla. of-*eIll Excayatii* Dia. of4}+ell Cartdrtp J,DonwsticlPrivata ❑ Gra P's—ck ..'-I TrpoV * rtype of Gis,ipg 9peciarAtiorm t i J Publlc' L] Other _ --I Delta "_ Devth of GroGt Seal __ Type of Grout :1 Irrigation ---Approx. Depth ❑ Eastern�r' f Surface Saa1 Inatallgd by rpt Repair Work pone LTypo of Pump _ l. .... N. State 4Vnrk Done Well destruction Well Dammar � Snrrlir�n�i4l�tdrJ�lvf+nnx'Vl Depth Flhar�laN al l8elow 550'1 TYPE OF SEPTIC WORK: NEIN INSTA't-'LAT100 REPAIR/AODM 0 N DESTRUCTION ❑ INo septic eyetem permitted if public sewer is available within 200 feet, �y Inetelletign wAl serve; Residence : .-]ComrrrarciiW_ Other i r _ Number of N.m r of b6drg'Qmu , Character of sail to a depth of 3 feet; Water table depth SEPTIC TANK E -Type-Mfg PICC, TREATMENT PLT, C l Method of Disposal r ` 6 Distance to nsares,: Well —__. Foundation _ PropwtV Lim ` ! LEACHING, LINE 40. 8r Length at lines Total lengthzsi FILTER BED LJ DiStanCe to rc3rest; Wdl F�unda#ipn } Property 1<Fltc ...._.,- 5EEf'AC.E RITE Depth " f � ,r Size � Nurllber L-J. .. SLIM�s L- Distance to nearest; Weill Foundation Propert}� Line_-- DISPOSAL PONDS I :f}, j hembytertlfy that I have pr6pari3d .tris appNcatian and that the work will be dant in acoard8nce with Son Joaquin county ordlnanees, stAfIaws, and rules and regulsthYns of the San Jonquin Local tiealth district_ Hama-owner or lioansed scent's Signature fortifies the following; "I certify that in the performance of the work for which We permit is imkied,1.41all not employ any pwaon in such -manner as eo heoOme subject to workman's.rpmperqQrtipn laws of California,"-Gontractor'e ihiriog.or sutnGontraoting' ignetum eertifmk the following; "I certify that In the rF Brno§of thi'vwark for which thio permit is isauad, 1 yhalI ar4loy Owns 94jeat to workman's rornWns8- tion laws of Califwnie." The appycant t all for wired" Complete drewi g on reverse side. Signed]C - -TTi#ia �_. _ Oata: La- - _ Fl�EPARTMN7 IJ E ONLY 1 l*tel Apvkatlon Accepted&yr Date Aria Piit Ot Grout Inspection by late Kirial Inspection�by�-� Additional t;cmmentw - Stk 466-"l Cl Lodi 365-3621 13 Manteca $28-7104 ❑ Tracy 835-8385- Applicant- Return alt copies to! Envirpnman I Health PermRlSarvlCes 1601 E, Hazalmn Avg„ P,0,.Brax 20W. Stk., OA 95291FEECKr INFO AMOVNTI)UE AI%Db7� -RE�IITTEd S ri RECEWED$Y DANE PERMrT'NO. i Era 13 24 MrV.1&4u: €H 1+26 111 1