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_..: APPLICATION FOR PERMIT ., SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F. HAZE ON AVE., STOCKTON, CA Telephone (209) 466-6781 ? PERM_IT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is horehy made to the Sen Joaquin Local Health Distract rpr t Pe No it)construct and/or jns1.i'I the work herein scritxd. deTMs app6catrnn's made in eomplwnce with Sar,Joaquin County Ordinance NO.549 lot sewage or No. 1tNi2 for well:pump and rho Holes and Regulations of the San Joaquin Local Health District Lot S-te C _ PM - Job Address Address Owner's Name W - Fi License Y- , tvo — _1.7(�2 z � f>none3OI ,O .b' Addres. _ r` COnhDCf - DESTRUCTION NEW WELL C] WELL NLPLACEMENT C. TYPE OF WELL/PUMP: r OTHER Cl -- PUMP INS ALLATION C SYSTEM REPAIR Li SFWER LINES _ DISPOSAL FLD. PROP.LINE DISTANCE TO NEAREST: SEPTIC TANK _ OT'riE _ - PITS/SUMPS FOUNDATION _-_ _ _A.r71CULTUR_WELL -- _--'-N VlELI-_ --- --- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION`,PECIFICATIONS / ti '- Dia.of WeU Casing - [:Irrlustrisl U Open Bottom C Manteca Dia.of Well Excavation $peglreatlons ` i Type of Casing _ - C j,. •• C7 D'.nVjtic/Private Cl Gravel Pack 7 Tracy Typ+of Grout___--- -- , C"1 PuCI::.... l-i Other I.Delta Depth of Grout Seal _-- ,+ I I dripanon -__Approx.Depth I I Easlem Surface Seal Installed State Work Done Repair Work None L] Type of Pump - - H.P. _.- -- -_------- t l •Well Destruction. 0 Well Diameter Sealing Material(top EO') -------- - Depth er Mater a'(Below to'1 ---_- -- 'I "-- rmitted it rbtre sewer is TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR ADDI�TION� �DiI�ST�R[1/y�CTIGN (NylabN•t'wrtMn 200 feet.) , trisiaNation tkip ricrac: Residence_ Commercial Othe&mwkN �d Number of living writs:_— Number. bed ---- O . - - - ___ Water table depth Character of soil to a depth of 3 feet:-rdd'' No.Compartments SEPTIC TANK Cl Type/MlpCaraciry- Method of Dispo*,A _ PKG.TREATMENT PL'T,C Drstwtce to nearest: Well Foundat on._.__ Property Una__-- Total length/srle--_— ,/'�•� } LEACHING LINE C No. Length of tines -_--- Pr,� Line FLLrER BED U d Da aned to nearest: Well_-_-. Fountion - PertY --- Site-_.K 1 SEEPAGE PITS T ySUMPS [.l Distance to nearest: Well"1.� - Fouo:!arion �j a+ Property Line_s� } DISPOSAL PONDS [7 d 1 Mnby wriity that I have WKyred this application and leu the work will!�e mono in accordance with San Joaquin eounry ordinances.stats laws.and K J ruloe and reptrlatwrte of the Sail Joaquw local H"th Drl:trict. issued,I shall n,t -.Hoar ownp or lice nsed apemrripr 's iature certifies the fosowina:.'I cartrfy that in the performance of the work lot which this permit.u compensation laws of Cakfotr"."Conitscton0 es hiring or sub-eoW racrinp ruWwrtee employ any person n wch manner es to become wbpct w workman's compo t to workman's cornpensa cwwwg the following:•"1 certify that n the peAwance of the work for which nthis permit u issued.I shall emplcY persons suhle t+On lacca of Won nia." r. The ePplirrK cd for is napections.Con,pbte drr.ra awing ove 7o'11J- .,�.. f< Sgrwd X_— _ Title, Dote: c FOA DEPARTMENT USE ONLY / ' _ k Data ��!/—Area _1,�.— r Appficetion AccWAW by y f� Find Inspectors by _ Date �a Gra.t i+iePection by � stc�� _ Addhional Coinvrtents: -—-Tracy v 823-7104 ~ L7Stk 4054701 0 Lode Appiki ad Ull l -10:� Manteca orrmsntalth P in l Heat/Seres vic1/:01 _❑Hail on Avv,�P.O. Box 2009, Stk.,CA 95201 - K RECE.VED BY DATE PERratT NO. ., I i FEE - AMOUNT DUE Aypl•NJ REMITTED CLASH RrfO .nruasutEv,,.err 5 R ( Oo lU ry �.ter,.,.:. . r }