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-r t /-+ b APPLICATION FOR PERMIT SAN.JOAQUIN.YLOCAL HEALTH DISTRICT t 160_-_:. HAZELTON AVE., STOCKTON :GA r at f Telophcrte•(239)'466-6761 s PERMIT EXPIRES i YEAR FROM bfl7E ISSUEDr' a t 4 i {Cotnptete n_Triplicatel g Application is hereby mad::to the San Joaquin Local Heall R'.•trict or a permit to construct and/or install tfie work herein described.Thio applicatior.n hr �xr t made in compliance with Sen Joaquin County Ordinan'e No 533 for sews a or No 1862 for well 1pump and the Rrites and Regulations of the Sen Joequm ,Luca!Health District i Job Address �f l',( L!J! !Y �` } ✓ Crty l at Size f PM x f r i £tel Owner s Name !j.T�nJ; ti r3 LL_ Address Phoria Contractor's Name License No. ' " Phone :TYPE OF WELL PU1�1P W.WELL ❑ WELL REPLACEMENT ❑ } DESTRUCTION U PUMP INSTALLATION Q SYSTEM REPAIR # OI HER 3� �4 DISTANCE TO NEAREST SFPTIC,TANK SEWER LINES 01SPOSAL FL3. PROP `LINE _ tfa FOUNDATION AGRICULTURE WELL OTHER WELL'' PITS/SUMPS aal �'y INTENDED USE TYPE OF WELL PROBLEM AREA`': CONSTRUCTIOIJ SPECIFICATIONS53 13 IndustrialQ Open Satttxn ❑Manteca Dia.of,Well Faicavatron iia of Wall Cas'n 9 ❑domestic/Ptrvate 0 Gravel Pack ❑Tracy Typo ofPCasing SpecdicationsA zCJ PUW ❑Other C1 Delta Depth of Grout SW Type of Grout ❑ Irrigation 0) Depth _ ❑ Eastern Surface Seal Installed by Repair Work Done.,, 6 T of Pain H P State Work Done x -� Wea Drstructicn ❑ Wea Diameter Sealing Material ltvp 501'° , " � f 5r a peptti' Filler Material f Below 50 1 Y r c T,PE OF SEPTIC WORK:..NEW INSTALLATION G PEPAIR/ADDITION EX DESTRUCTION Llm{No septic systepermitted d public sewer rs e % available within 204 feet 1 ' �� ,' 's ' Irts!.:tabon wanMc serve , Residence -C`ommereial__ Other.• r t h Nt Faber of-Crying units / RlVumber of bedrooms `' � }' >{ ChareVter of sorT'ty a depth of 3feet /�t� ,�,�+=°�•�� > Water table depth d SEPTIC TANK ®' Tyge/MTg L n'�( = Capacity,✓ hu. Compartments s ': PI<G:TRFATMENT.PLT:❑ MetKod of Di-aposr ' jal' Distance to nearest Wer Foundation 1 Property ins ` 5 „fir IF LEACHING LINE ❑ No.8 Length of lines Total longthisize i" I *F r *4 FILTER-BED L7 Distance to`nearest W011 im_ Foundetioa' y _ Propoftl line SEcPAGE PITS ❑ ' Depth Size Number SUMPS' E l Distance to nearest Well Foundation Property Line DISPOSAL PONDS - ❑ F' ' hereby certify that I have prepared this applicatioh and that the work will be dorto in accordance.with San Joaquin county ordinances'state laves end , R.t s' edea end regulatioru of the San Joaquin Local Health District. i3•, Home wnor Gm cansed age 's slgnatunr carT"ms the foliowinp:"I certify that in the performance of the work for which this permit is Issued I chat{not oer cmptoy any person in such manner as to become subject w workman's compensatiyn laws of Cal'rfomia."Contractors hiring or subcontratting signature' cers the foeowing:''1 certify that in'the performance of the wcrlc for which this permit is issued,- m I shall eploy persons subject to workman's compense dlre tion laws of.Cai"dornia"'. . , p_ The applicant must cell for F,7 required inspects is Complete drawing on reverse side 3 Signed14 }` Tttta: Date: FOR DEPARTMEN—USE ONLY x t AppGtatior ed by Y Area �� y Date ` r ' �=0 11 Date Final Inspection by_ 7 T ' Detn Pit.ar n by .,..,c- Additional Corrunentx:- } 0 Stk 486ZM L. Q Lodi 369.3621 O Maniacs 8237164 ❑Tracy 83&&8385 , x ' Appficam-Return or.copies to:Emironmsntal Has"Permit/Services 1641 E. Hazelton Ave., P.O. Box 2004, Stk.,CA%MI i - rNFEO AMOUNT DUE AMOUNT REMITTED Cr'Y RECEIVED BY DATE PERMfT hlC1: I ,�a,{f J •FN 1}14[RLV 7011a1 ` LJ �J II 1�"> y ' 1 Err.2a