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_ .. .. .. .. ..,. _ -• ,. _" .., .. `.'�;. 'Yy",1:.7,.: - .h:..., ;,�1`4�:h.:fclv+Tin•u'�tar!^.'i " APPLIC iCN Fo; PERMIT SAN JOAO:.. LOCAL HEALTH J11�'RICT 160 C. HA TON AVE., STOCKTON, CA PERMIT 110. Ielepi, a (209) 466-6781 DATE ISSUED PERMIT r1PIRES I YEAR FROM D`TE ISSULD (Complete in Triplicate) ' App11u tion is hereby made to the San Joaquin total Healtr District fora permit to construct anc/or install the work herein described. This application is made 1n compl lance with San Joaquin County Ordinance ho. 549 for sewage or No. 1862 for well/PLOP .Y and the Rules and R ulation of a San in iota'. Health District. Job Address a o ✓ (1.0 S�ubrdivplsrlon Nome Owner's Neme _Addrrss JJ /J S0� v _Phone er, 1 ' Contractors Name License No. Phone TYPE OF WELL/DUMP WORK: NEW WELL G1 WELL REPLACEMENT ❑ DESTRUCTION❑ f� �.; PUMP INSTALLATION ❑ SYSTEM REPnIR ❑ OTHER EJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE S FOUNDATION AGRICULTURE HELL OTHER WELL. PITS/SUMPS INTENDED US: TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �]industrial [�Open Bottom ❑Manteca Dia. of Well Excavation r ICY ❑Domestic/Private ❑Gravel Pack ❑Tracy Die. of Well Casing S i Public f—Other Delta ; ❑ J ❑ Type of Casing V irrigation Approx. ❑Eastern Specifications a' ❑Cathodic Protection Depth Depth of Grout Seal r ❑Geophysical Type of Grout . Other Surface Seal installed by T, + Repair Work Done Type of Pump H.P. State Work Done , " Well Destruction ❑ Well Diameter —Sealing Material (top SO') If 141• Depth Filler Material (Below 50') } if TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION (No septic tank cr seepage Diavailableewithinu20ocfeete) is.. r4 lnstallAt!,n will serve: Residence Commercial Other �s§ Number of living units: Number of b rooms Lot sue I of Water table depth Character of so 11 to a depth of 3 feet: �Ya UC o Z ? � 4� SEPTIC TANK lAl Type/Mfg �t Qq!L l � Capacity 00 .No. Compartments E' ! Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Tipe!Mfg Property Line - e� SEWAGE SYSTEM r7 Distance to nearest: Well Foundation D Y DESTRUCTION Total length/size h ro LEACHING LINE ❑ No. G length of lines 'u FILTER BED CDDist>•".ce to nearest: Well Foundation _ Property line SEEPAGE PITS Depth Size Numbar Distance to nearest: Well. Foundation Property Line SUMPS U DISPOSAL PONOS ❑ i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin crunty I �t1iz her.nces..state laws. and rules and regulations of the San Joaquin Local Health District. ordin Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall not employ any person in such manner as to become subject to workmant compensation laws of California : "I certify that in the performance of Contractor's hiring or sub-contracting signature certifies the followingthe work for which this permit is issued. I shall employ persons subject to workman's compensation laws of California." s The applic must c f equired inspections. Complete�Awing on rpierse side. L/. I-� Date: 1 y Title: `e/1M4vs Signed FOR DEPARTMENT USE ONLY Stk 466-6781 i Application Accepted by Area ❑ . ❑ Lodi 369-3621 ?' Additional Convents: ❑ Manteca 823-1104 Pit or Gout Inspection Dy Date /yl Date ❑ Tracy 835-E385 Final inspection by �!1 Applicant - Return all copies to:"Envirental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �IEIMITNO.iNFO ' 51 -i 5•� 10/82 500 EH 13-24 REV. 1002• %-7q 14-26 �«w..nca[w�.mwaw��+'*asia.�llaexoal`k5�.a4,Zi.3+!`vfe �:•_r v}.,t..��tt'-�ai�-+�'+ 1yE''-$ lib- 'F.4 .t�4."c 7N, i.- t' f Yiu r„ R �S'1^+�11Y'•(R.