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..-��. .V .p.-M-TIY' :. �-•r �♦ /j`f�jr}j��/US/J1 1.O' \ APPLICATION FOR PERMIT VL' tea/ J�/(•,ry�/f SAN JOAQUIN LOCAL HEALTH DISTRICT f""Ap 1601 E. HAZELTON AVE., STOCKTON, CA �+ r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 /V ©� I (Complete in Triplicate) ` 7jlR n` s application is Application is he made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described• made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for wail/pump and the Rules mations of San Joaqu' Local Health District. ; � r ) city J Lot srzs PM Job Address r � Phoria r.-�+! L — Address „® Owner's Name � _ � ? y �— Phone r License No. ConWELL REPLACLltractor's Name ' ' EMENT DESTRUCTION ❑ TYPE Of WELL/PUMP: NEW WELL v OTHER 11PUMP INSTALLATION L1 .� SYSTEM REPAIR � DISPOSAL FLD. PROP. LINE — DISTANCE TO NEAREST: SEPTIC SEWER LINES _TANK AGRICULTURE WELL OTHER WELL PITSlSUMPS i t i t FOUNDATION INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' Dia.of Well Casing ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation G Tracy Type of Casing----- I S -L ad¢n-s� ,'S 3 ❑ Domestic/Private ❑ Gravel Pack ;Type of Grout• 1 C7 Public C Other Delta')r• Depth of Grout Seal Surface Seal installed by ❑ Irrigation --Approx. Depth [71 Eastern H.P. State Work Done Repair Work Done [I Type of Pump - . .,. t Well Destruction ❑ Well Diameter Sealing Material Itop 501 1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW :715 `5 REPAIR/ADDITION Cl DESTRUCTION avaiiabpe wl(No setic tlnna200 feettd;rf public sewer is ' Other Installation will serve: Residence Commercial —3 i Number of living units: —/— Number of bedrooms �3 — '''*: - 3 L e}depth Character of soil to a depth of 3 feet: (a$?' Watertabl: Nor,Compartments SEPTIC TANK J� Type/Mfg t �;,'Capacity ' "` Me of-Disposal PKG.TREATMENT PLT.❑ e* ' `' -� — >Oandation�-- Property Line 4 Diistance to nearest: l�a f� No &Length of lines' %,- - Tot),(le g'th/size LEACHING LINE . 9 , , , Property Line �� Foundation � FILTER BED ❑ Distance to nearest: ,. `SEEPAGE PITS Depth SizeLi FbundBtion 3 Gulope,, ',I� SUMPS ❑ Distance to nearest: Well d0 s DISPOSAL PONOS C certffY that l have prepared this application and that the work veil{be done in accordance with San Joaquin county os,an rdinances,state law I hereby rules and regulations of the San Joaquin Local Health District. rmance of the work for whichthis stsppermit is issued,I shall not pHome owner or licensed agent's signature certifies the following: "I certify that in the perfolaws of California."Contractor's hiring or sub-contracting signature; employ any person in such manner as to become subject to workman's compensation certifies the following:"I certify that to the performance of the work for which this permit is issued,I shall employ Puns subject to workman's compensa- tion laws of Califo ia." The applicant mus c for all requir inspections. Complete drawing on reverse side. `'�_ Date: 3 Title: Signed FOR DEPART ENT USE ONLY 4Of .i jj Area t/ i Date Application Accepted by� r Date —,� Final Inspection b � Date � �� Pit or.Grout Inspection by , Additio(M'f Comments: w —�� 835 6386 [I Stk 466-6781 Lodi 3693621 ❑-Manteca E�23 7104 ❑Tracy 5201 Applicant- Return all copies to-, Environmental Health PemiitlServioes 1601 E. Hazelto n Ave., P.O.Box ' S ''ICA 9' } PERMI7'NO. CK DATE FEE AMOUNT REMITTED l CASH RECEIVED 8t' INFO `� OUNT DUE L, :+ EH 53• 142 142 AEV.70/631 �.'•^O o. - �- - . � ,,. ..--� .-,.-.•.--.-..��-.�.-+.•� e � - 5-� .--_�..-..•r _H 14-26 -' - -•-- ''-'r---- -