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f� r F Sof.. tt iA APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA; Telephone (209) 4664MI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) , Application is hereby made to the San Joaquin Local Haetth District tot a permit to Construct and/or insto the work herein dosertl W.This applaation Is i+ . m_We i,.1 compliance with San Joaquin County Ordinarree No.533 for sewage or No.1882 for wellipump and the Ruta and Regutatipts of the San Joaquin Local Heahh District. • .F�*4 Job Address L Or /—t'it�—�ot Size PM ie h< ow `a Name dem �d t!/'t�A2L� pno,>e Z!a– : " Contract, Addres5'�� License No. Phone t. TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ' DESTRUCTION ❑ f, PUMP INSTALLATION ❑ SYSTEM REPAIR :�l x OTHER ❑ tkl DISTANCE TO NEAREST: SEPTIC TANK SEWER:LINES DISPOSAL FLD. PROP..,LINE FOUNDATION AyRICOLTURE WELL,'______ OTHER WELL PITS/SUMPS �cIRJ - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial E,Open Bottom Ci Manteca Dia.of Wen Excavation Dia-of Wel Casing g, C Domestic/Private 0 Gravel Pack 4 Tracy Type of Oaring - SPKillicAtions. C. Public i Other ❑ Delta Depth of Grout Seal Typo of Grout u Irrigation --Approx. Depth ❑Eastern Surface Seel metalled by— Repair Work Done i Type of Pump H.P._ 'WO Work pang Well Destruction Well Diameter Sealing Material Itop SWII , _ Depth Filler Material(BekNr38) KTYPE OF SEPTIC WORK: NEW INSTALLATION❑ .REPAIR/ADDITION DESTRUCTION Cl (No septic system permitted if public=war is available within 200 feet.) " zy Installation will serve: Residence_ Commercial Other Number of living units: __ Number of bedrooms Ea i) ley Character of soil to a depth of 3 feet: Water table depth , SEPTIC TANK C1 Type/Mfg Capacity _ No. Compartments A5. PKG.TREATMENT PLT.E7 Method of Dial $ Distance to nearest: Wen Foundation Property Line 4 ,` LEACHING LINE G No. & Length of Eines r '� !f ,Total length/size FILTER BED ❑ Distance to nearest: Well Fourrde" PMP" � l- SEEPAGE PITS Dis epth Sa �� Number . sum, -73Distant oto nearest Well Foundation Property Line, Till ` DISPOSAL PONDS I hereby mnity that I have prepaf6d this application and the fie wotk will be done an accordance with Sar,Joaquin county ordinances.state laws,and Ft rules.end r ulations.of the.San J uin Low!Health District, t eg - 4aq Horne owner or licensed etfern's signature certifies the following: '9 certify that in the perfo,mance of the work for which this pe n+it Is issued.i shall rwl employ any person in such Rlannor as to become suboct to Workman's compensation laws of California."Contractors hiring or sub-crxrtrecthq ArIlI urs }.a. certifies the following:"I certify that in the performance of the work for which this pamtit is issued,l anal employ parsons subject to workman's eompense- tion laws of Callfornie." The applicant mus for 1211 'red Inspectionsreverse side, Complete drrMng on reveside. fSigned - Tina:—�.��- Data: FOR DEP RTMENT USE ONLY d .» A ion Accepted ler Date Area _� or Grdui 1 tspection LY Data V Flnsl InapeetIm by Data lip Y by Additional Comments:1 p of u-MA S– Z 1 L7 SNI 468.6781 ❑ Lodi 3W3621 El Mantecir Sn7104 d Tracy 83I&WESrp 7 Applicant. Return an copies to: Environmental Health PertrlhiServieoa 18D1 E. Hazelton Ave.,P.O. S 96201 w FEE 0 AMOUNT VUE AMOUNT REM rr-[D CASH. RECEIVED BY DATE PERMIT`NO. tH1}}r lRrti'.• w w! / til 14.2e ::.�.-.-:�F. '=":.at..iftiPY�r.F -:�:Q:. :-.�+ f'.. �'..'k.�r.ei'.:v:.:A:tr..__:-ti^4s:. .-�-..._� �r-.-.- ...�� .aro� .. :+_:.t+,+,r.�<J+:m..��'�?F3i.._:r:"�'�� -..�.:#°_.•_-rw+i.W.��....•..,,�...�i'.w°�.w.