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.. :....Y�SJ..%V t:.1;.Rs•.'wl v_Ps 106r .^•a.. ..riix._•a:7i.A rw11�o.•y a...�..a a-:a�i.,.� :......r.. r i APPLICATION F 1R PERMIT t SAN JOAQUIN LOCAL . ':ALTH DISTRICT - . 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 �r1. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) { �" 4 r Application is hereby made to the San Joaquin Local Health Drst►ict for a permit to construct and/or irrsta0 the work heroin described.This appncauon is -w a made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rubs and Regulations of the S9rt.loa4uk1 Local Health District. 9G city v L Lot size Job Address T �� Phone Owner's Name Sn /1 r f I dt 7 n + Address . . .... - DLJ -Y '� Contractor�� r Ae.dress �a n r License No. Ph. w -' WELL REPLACEMENT ❑ DESTRUCTION O TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ PUMP INSTALLATION ❑ SYSTL•M REPAIR ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t" FOUNDATION AGRICULTURE WILL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I n Bottom ❑ Manteca Dia.of Well Excavation Dia.of Well Casing ' ❑Industrial ❑Opa Specifications ` $ ❑ Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing t p Public ❑Other ' ❑ Delta Depth of Grout Seal Type of Grout M r'. ❑Irrigation __4pprox. Depth O Eastern Surface Seal Installer by Repair Work Done ❑ Type of Pump H p State Work Done Weil Destruction ❑ Well Diameter Sealing Material(top 501 _ Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION DESTRUCTION❑ available within(No se;tic system e200 feet.) d Public sewer is ' t Installation will serve: Residence V11, Commercial_ Other r4 { Number of living units: Number of bedrooms — Water table depth ` Character of soil to a depth of 3 feet:_T I ,t^ of P/ Capacity — No.Compartments ' ti SEPTIC TANK ❑ Type/Mfg Method of Disposal ti PKG.TREATMENT PLT.❑ Distance to nearest: Well Foundation ;�:s Property Line — y Total length/size . 7�T— LEACIIING LINE ❑ No.&Length of lines �, r Property Line ' FILTER BED ❑ Distance to nearest: Well Foundation . 3 - Size Number SEEPAGE PITS ❑ Depth Property Line SUMPS '❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances.state laws end<' r rubs and regulations of the San Joaquin Local Health District. {wed,I sha0 rot ; Home owner or licensed agent's signature certifies the following:"I certify that it the performance of the work for which this permit rimploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature ? . "arttfies the following:"I certify that In the performance of the work for which this permit is issued,I shall employ persons subject to workmen's compsnsa Pj 3 tion laws of California." S r T1te applicant must call for all required inspections.Complete drawing on //r��everse side. Title: lrY�1 I Date: • c T'Signed y IA.✓ pd Ls/ S - / FOR DEPARTMENT USE ONLY _ r Date Area Application Accepted by Date Pit or Grout Inspection by naI Inspection by__1//!r Date ' r .1y ; Additional Comments: j` p C3 Stk 466 8781 ❑Lodi 369-4621 ❑Manteca 823.7104 ❑Tracy ;4= z Applicant-Return all copies to:Environmental Health Pemtit/Services 1601 E.Hazekon Ave.,P.O.Box 2009,S lc.,CA 116201 i CK RECEIVED BY DATE PERMR'N0. ( IFEE FEE NFO AMOUNT DUE AMOUNT REMITTED CASH _t +EN 13.24 IrIEV. ENI 14-25 u<s..:r.ac•tnto:.a-......:,..+ .. _ .,.. i-LiS.'t moi''+'-.:r;C:1�.s3..` s.>.;:� �? Se