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A tr'rl"•x "*'Ai+V 41'•, t1 Ctc }l, ��' r 'M ryYh�( •�.ry�y9 � e -+t It t C R ,L "'r �•�� d!r �fi t". a +� ""^r } CC r+ +„ - '79r Y n �ty +.,� +'MK{ 'k 47`r�'/Gti 0.u ; �,^+ rt tuba , 3+�Z ,•�1'1 r °� {. �MIMF avL, APPLICATION FOR PERMIT !;AN JO^.+.2UIN LOCAL HEALTH DISTRICT 1F�S1 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ;'I F PERMIT I_XPIRES 1 YEAR FROM DATc ISSUED " (Complete in Triplicate) : Application is hereby mader',o the San Joaquin Local Health District for a permit to construct andlor install the work lwain described.This application is made in compliance wit-•S:rn Jooauin County Ordin ince No.5491fc�f sewage or No. 18f,2 for well/pu�p and t RUlas and RegulatiOm of chs San Joarlukt 2� 1 c =� Local Health Distric.+, � � t-i•7�r ;r iS •fir.` � - ` \\ n Job Addres:r22,� /JG,oiyE Citti _ Lot Sire PM /. L L re.✓ r C. C-/yE�//� Phone _ Namer's Nae ?1'v.�C�_.,._ Address .1_-� r C r�� 'IAddiessL✓"� "^"'�-' License 41370�I Ph �. cntractgLl�t. T'i PE OF WELL/PUMr': NE%4 WEL'yF,�+/' WELL REPLACEMENT O DESTRUCTION ❑ J PUMP INSTAI_LAT;ONSYSTEM REPA!9 ❑ OTHER 0 DISTANCE TO NEAFI::i_'_SEPTIC TANK -- SNVEr3 LINES , DISPOSAL FLD. PROP. UNE - .},, FOUNDATION __ ACRICULTURE WELL --- OTHER WELL PRS/SUMPS _ s;nR cr INTENDED USE TYPE Of-WELL PF:OBLEM,IREA CONSTRUCTION SPECIFICATIONS 0 Industrial �D tl15on Bottomu L1 Manteca Dia.of Well E wva/on-�/ Da.of Well Casing 'y-q'1Somostic/Private 0 Gravel Pack ❑ fracy Type o1 Casings?!� L SPecificetior+s M Public ri Other n Delta Depth of Grout Seal _ �Q� _ Type of Gra t + A rrigadon Approx. Depth I I Eastern Surface Seal Inetaltad try P+puit Work Dora ❑ Type of Pump H.P._�,� State WOrit Done--_ Well Debaructior, ❑ Well Diameter Seating MatnnAl'top 50'1 �- y Depth_ Filler Mmm:ai;9a,ow 50') --. TYPE OF Sf.PIIC WORK: NEW INSTALLATION I I MJ'AIR%ADC!TION I I DESTRUCTION I I INo septic system permitted i public;sewer is available within 200 fereLl ! D installat will nerve: Residence-- Commercial__-. Other NLn+bet of)ivint,units:-- NumScr of bedrooms Chrrecte:of-A to a depth of 3;eats___- -__ y/ater table depth I� Sr?Tit;TANK El Type/Mfg ----- -- Capacity No. Compartments PKG. TREATMENT PLT.L1 Method of Disposal Distance to nearest: Well Foundation - Property Line_ LEACHING LINE 11 No. &Length Lit lines __---_ Total ler q hlWt FILTER DED `_j Distcncer to rre,rest: Well Foundation Propuny Line SEEPAGE f`rTS it Depth -_-_._-_Sire __ _- Number!____ SUMPS la Diftance to nearest: Wel,_ Foundation_ Property Limb DISPO`W-'ONDS [l t herrr+by certify that I'`ave prufr.red trJb aprlicatlon And that the work will L9 d na ir,,::c vdanco wn with San Joaquk.cunty ordinances,state taws,and rubs or-rd regulations of the San Joaquin Local Heaitn Home nwner or licensed agent's signature cnrtifies my foftowiog:"I certify toat in tire praicvma tce of the work fcr +:.^++this permit is issued.I shell not ampioy any pntturt in:such manner as to_»come subirct to v cr&man's compensAtron laws of Califonra.'Contracto(s hvitn or sub-contractirtd signature - cat-Wins the foliat-ing:"I certify that in the performance of the work for wfr,ch ttvs permit is isvr.+),I shad employ pmsr"%biped towakman's compenaa- ' tier,laws of California.- The applicanEM+ t cr,ll for all rgquirer fr spettiors. Comdota draw ng on jav_,saa sidee.. L �.l�f�f � Title: - Date: FOR DEPARTMENT USE ONLY L. ' AvVllcauon.4cu'rated by -__----.-- Date Pit or Cr.rut Inspection by - LL _ Dace JiFinal Inspection by L1 .ritk 466-f'781 ❑ Lodi 3t19-3621 C] Mnntaca d217ICA tJ'racy 835-8386 AppHcrtti• Qvirturn all copies to: Environmental Heath Psrmit/Servrc+'.s 19L)i E. Ha.tetion Aw., P.O. Boa 2000. Stk., CA SS201 mau CK► ". FEE AVOUNT DUE_EMOU!+'1 REMITTED �— RECLNED BY DATE PE:RMtT ItO. .• - �� INFO _ II +yri+tyY tltN., .t'1 rj -)�-� "YY / /J G) -',.?G fl C 'v 0jT1 .'�r'�i Y u w1r1!ly xbVE -