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R1 yaw 1s�a>Z f�:•. •t'7� �",' -{'1 a r. r APPLICATION FOR PERMIT `• SAN JOAQUIN LOCAL HEALTH DISTRICT JUL , 5 �g9i 4` R� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)466-6791 ENVIRONMENTAL.HEALTH -. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMtT�SERVtCES. (Complete in Triplicate) ,. r i•rs.:e.+�, "%fah •>i ` Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs apptication.is Y; made in compliance with San Joaquin County Ordinance No.549 for sewage or No,1862 lar welllpump and the Rules and Regulations of the=an Joaquin n,t ,•, a i; local Health District. 3 f, Job Address –14M -N—Hey-A& City Lodi Lot Size PM sOwners Name Add.:,1434'5 N. KV ^ ._PlFono - �. y'� �r fly+,#�a� I P. 0. BOX 113— yyy�� "Contractor '{�EO N, PiI� Address 17754 N. FIVy. �. Led. 95237 License ti+f'^"'1 Phone 'fa TYPt OF WELLlPUMP: NEW WFLL 0 WELL REPLACEMENT n DESTRUCTION L7 va PUMP INSTALLATION ❑ SYGTEM REPAIR Kid 9fi#EIF r' yr soy+l ' OISTANCE,TO NEAREST: ';XPTIC TANK SEWER LINES DISPOSAL FLC.___,_ PROP. LINE fw FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS'SUMPS R INTENOEp USE TYPE OF WELL PROELEM AREA CONSTRUCTIOn SPECIfICA11ONS u Ll Industrial -�:',p [,7 Open 9onom L7 Manteca Dia.of Weii Excavation _ Dia:of Wen-Casmg- •'5 '�- ft }•"� -'+ Cl Dor Dawe/Private ElGravel Pack ❑Tracy_. Type of Casing_ Specifications f 1 Public " f:1 Other [)Delta Depth of Grout Seal �.. . F I I irrigations ;r ,_ •, Approx.Depth i I F.astarn - SuAaee Seal Installed by i o�,�,,'�� Ropes Work Done' 0Type of Pump TU1�1iE12 H,P. State Work Dona �`�� Turbine F� f9 We11 Destruction ' n Well Diameter Seating Material lisp So') 4k, DepthFiller Material(Below 501:" V .TYPE OF SEPTIC WORK. NFW INSTALLATION I I REPAIR ADDITION l I DESTRUCTION I I iNo septic system permitted if pubirc sewer la o- r available within 200 feet.1 a a` tnsrallati6n will serve: Residence_ Commercial Other IF #?f,°r�'" T - ••-- '� a y } F 1w 'y w�5"�3�t� 1, il d. Numher of living units:T� Number of bedrooms_� ' ., �r�} � a♦ M 1r�� wT1��r�v� , I Character of soil to a depth of �° rr.3. hf 3 f --- ---Water table depth"" is d SEPTIC TANK° ❑ Type/MfgCapacity No.Compartments" y" r ty t a. PKG.TREATIWENT PLT.❑ Method of Disposal T D'estanee to nearest: Well Foundation ..,.,• Property Line 9p �°� iso •• 2 LEACHING LINE El 'No,&Length of 5nes Total lengthtsize FILTER BED:' ❑ Distance to nearest: Well Foundation _-Property Line 'SEEPAGE PITS I 1 Depth _Site Number $ �xi SUMPS �` 1:1 Distance to nearest: Well Founaation Property Line DISPOSAL PONDS' C7 t I herebycert( that I have prepared this a certify p p application and that the work will be done in accordance with San Joaquin county ordinances,state laws,ander rules and regulations oft San Joaquin Local Health D3trict. a + s- Horne owner or)icon ant's signature certifies the following:"I eenily that in the performance of the wok for which this permit Is issued,I Mall not 11 - - amploy any personi manner as to become subject to workman's comp•Insation laws of California."Contractor's hiring or subcontracting signature certifies the follow' certify that in the performance of the work for which this permit is issued,I shall employ pArsans subject to workman's companss• is#!.' =R" '•k'?" ¢ i+ tion laws of rho applicant r wired I apeetions.Complete drawing on reverse side. y }t Sig X Title:-_ Uate: __07/12/91 F R D ARTMENT USE ONLY + - Application Accepted by Date��E7 ' LJ I Pit or fir 'Inspection by Date Final Inspection by V oee 0// Additional Comments: e 'kt ❑Stk 466-8781 ©Lodi 369-3621 Gl Manteca 823.71116 C]Tracy 835-9385 4�' rr Applicant•,Return all copies to:Environmental Health PeriAt/Services 1601 E.Haealton Ave„ P.O.Bax 2009, Slk.,CA 95201 k t ' IO AMOUNT DUE AMr1UNT REMITTED Sn RE[FlYED 9Y WDATE PERMIYNO. - '? •eM 11r24(11". rIC. Y1�11 / /� / ! _ NI` - #• - 'ti• .y FH te.ze / /V V IIS ' ♦ ,ti s 4 i , 4