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, ya Pi A r LICATION FOR PERMIT . R—� — — t I AID # SAN JOAQUIN LOCAL HEALTH DISTRICT r LrBt't 1601 E. HAZELTON AVE., STOCKTON, CA _1/1t�n+ y� Telephone (209) 466-6761 vAC ft 3 PERMIT EXPIRES 1'YEAR FROM DATE ISSUI r (Complete in Triplicate) Application is hei eby made to the San Joaquin Local Health District for a permit to construct end/or install the work herein describe made a compliance with San Joaquin County Ordinance Health 549 for sewage or No. 1662 for well/Dump and the Rules and Regulations of the San Joaquin Local Health District. \ Lot Size PM Job Address1 �. 6 " Phone Address / r Owrior's Name • t ! �' icense o. ne �'--- ress —L � - a Contractor ESTAUCTt10N 0 TYPE OF WELL/PUMP: .NEW ELL ❑ LL REPLACEMENT ❑ bye'`,'" yA OTHER-Ul ( --- SYSTEM REPAIR ❑ '•✓ C„i FAOP. LINE PUMP INSTALLATION ❑ DISPOSAL gftt ! t1 SEWER LI ES „' � ITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK gGRICUL RE WEL OTHER WELL FOUNDATION tR. - TRUCTION'SPECIFIGAl'1ON5` T .( INTENDED USE TYPE OF WELL PROBLEM AREA t �P ❑Open Bottom ❑ Manteca ia. ot,Well Excavation I /� V�p fl ❑ Industrial ❑ Tracy Type of Casing ( �j{k�3��Ly14fr�Ya�ya,�rrff 1�fM1,� O Domill Private O Gravel Peck (1 Del Depth of Grout Seal VVTt`Z ZJ.7T k (1 Public ❑ Other j{ Surface Seal installed by , _APpm X. Depth f I1 tern �- S y-_ t t I I Irrigation 1 f State Work Dona 1i Type of Pump 1 H.P. .�...-.. SION ! Repair Work Dona O Sealing- aterial(top 501 Y" r / F k it Tat uce tiu nuu 1 Well Destruction O Well Diameter ^"' r I 1 it ( } Depth "T' I I Filler ria) (Below 50'1 ! z ! available within 200 feet) r - TYPE OF SEPTIC WORK: NEW INSIYALLATID EP IR/ADDITION 1.1 DEST UCTION I 1 INo septic s4¢atem permitted if public sewer n -i Corcial her 1 Installation will serve: Residence" Number of bedrooms Number of living units:_ ,Water to�`b`le tlep. Character of sail to a depth of 3 fear. �;` 'Ccrn rtm8nta . I Capacity SEPTIC TANK ❑ Type/Mfg t iAethod �; PKG.TREATMENT PLT.❑ = Foundation PropertYLine,t.. wj , Distance to nearest: Well .- t Ilength/Srae .Y LEACHING LINE O No. & Length of;irnes - 4� �� t ❑ Distance to nearest: Well Foundation Proper'tyaiir FILTER BED 1 - Size u or SEEPAGE PITS 11. Depth Property Line ` eC Well oundation y r SUMPS ❑ Dstance to re t r DISPOSAL PONDS O 1 hereby certify that t have prepared this applic�ion and that the work will be done in accortlance with San Joaquin county permit is i state laws,shat and rules and regulatiops of the San Joaquin Local-Health Districtg that in the performance of the work for whit this permit is issued,1 shall nal f ` Hone owner or lice)hsed-agelht's signature certifies the fell" '1 certify " Contractor's Of l i employ Certifies the following.nInl hir fY nit m the co ante subject to Wwork for which ch this perm vtion ¢issued, Iall employ Perso Object to wcorkmant's mmpensang e ii !1 h i tion Laws,of California." `I - . t ( The applicant must h for all r inspect hs. Complete drawing on reverse side. 4 A ler_,A�,A f I� Date: r (I Signed� �— �" E q FOR DEPARTMENT USE ONL` .Date 'Z Area Application Accepted by 4 Dace Ph or Grout ImPadiorrbY I r i Date Final Inspection by r i Ji T 11 835- Additional Comments: ❑ Manteca 823-7104 - j ❑ Stk- 466-6781 0-Lodi 389-3821 ,( ❑ azeb ��5 Stk., CA 95201 tt{ Applicant- Return all copies to: Environmental Health Permit/Servieea 1601 E. Hazehon Ave_ P.O. Box 2009, 1 i 1( RECEIVED 6Y DATE ! PERMIT NO. FEERMOUNT DUE INFO AMOUNT REMITTED SH k�9ItV11.�LIf �\— "a. I 711 'I I