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M Ar PL' :"ION FO PERv: 03 LOCAL <47H DISTRICT Q4 1�G1 E. HAZELTON AVE., STOCKTON, CA ------ - - Telephone (709) 466-6781 DATE ISSUED 3`��-8 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local He:.'th District for a permit to construct and/or install the work herein described. This application is made in cimpliance with San Joaquin County Ordinance No. 549 for sewage or No. 1867 for well/pump and the Rules and Regulations of the San Joaquin Local `Hea'lJ�yK�� r/��)GAc Job AddressT�/� /O'�'c4 Xf 1 Subdivisfin'Name -- ' Address 3vvn s _s. Q �- - Phone Owner's Name (Lt n/ f lYla n 1 A n ?�! 2 Phone �10 Centractor's NameLicense No. 1 TYPE OF WELL/FUND WORE: NEW WELL WELL REPLACEMENT ❑ DESTRUCTiON� (� • r,THER PUMP INSTALLATION'(� SYSTEM REPAIR L_l PROD, LIiL y DISTANCE TO NEAkE37: SEPTIC TANK _ r ' SEWER LINES _ _DISPOSAL FLD.,� �Q AGRICULTURE WELL OTJER WELL -PiTS/SUMPS FOUNDATION �--- Q 4' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d Industrial Open Bottom ❑Manteca Dia. of Well Excavation 1a TracyDia. of Well Casing `.. Domestic/Private Gravel Pack ❑ — Y� Delta rl. ❑Public ❑Other ❑ Type of Casing irrigations Approx. ❑Eastern Specifications - 1 1• Depth ❑Cathodic Protection Type of Grout Seat ❑Geophysical Type oe Grout j�Other Surface Seal Installed by 1{,P. State Work Done Repair Work Done[] Type of Pum? Well Destruction �{ Well uiameter _Sealing Material (top SO') Depth D r Filler Material (Below 50') ..� -+------ I. er TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION CJ (No tept'c tank or seepage pit iavai able within 20Opublicrmitted if feetis . ) installation will serve: Residence _ Commercial —. Uuier Number of bedrooms Lot site _ Number of living units: Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments 't SEPTIC TANK ❑ Type/Mfg Capacity , Method of Disposal — PKG. TREATMENT PLT. ❑ Type/Mfg • '-fOUndatibe' Property Line SEWAGE SYSTEM ❑ Distance to nearest: Well - DESTRUCTION Total length/Site LEACHING LINE I, No. 6 Length of lines Distance Prooert Line ❑ to nearest: Well Foundation + y FILTER BED j Depth Site Number jr SEEPAGE PITS Foundation Property Line SUMPS LI Distance to nearest: Well DISPOSAL PONDS ' 1 hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f the ., Hone owner or licensed agent's gent'semp?oyture personiin such es the fmanollernis to becomeysub,)ectthat ntohworkmanS compensetionwlf the California."lhic i permit IS issued, i ll Contractor's hiring or sub-contractinq signature certifies the followingnSationrlaws ofCalifornia. Of the work for which this permit is issued, I shall employ persons subject to workman's compM sem. g The applicant t call for all required inspections. Complete drawing on reverse side. pate: f 14 �- Title: S C� /fp/•� ____-- Signed x - FOR DCPA ENT USE ONLY./ /� ❑ Stk 466-6781 Area __-_,_�.(� Application Accepted by , f!liLodi 369-3611 Additional CommPnts: Date L_) Manteca 823-7104 Pit or Grout_Inspect;�4� Date -212_"�_ ❑ Tracy 835-6JA5Final Inspection by01 ) CA 95201 Applicant - Return all copies to: vices 1601 E. Hazelton de., P.O. Box 2009, Stk., RECEIVED BY DATE PERMIT NO. FEE BASE AMDUIIt DUE AMOU41-REMITTED _ INFO - N� �2� 7 $ - 4� C 10/82 500 EH 13-24 REV. 10/A2 14-26