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t*�t•,`�' APPLICATION FOR PERMIT �� •. SAN JOAC1UfN LOCAL HEALTH 1Dt5TMCT ' 1601 4 E. HAZELTON AVE., STOCKTON, CA� HAZEL TON 1209) 468-6781 R E G PAYMENT I ` ` LIVED .w . PI=FIMIT_EXPIRES 1 YEAR FROM BATE ISSUED (Complote in Triplicate) ' �.' Application is haieby made to the Sart Joaquin Local Health District lot a permit to ronstruct and/or install tho work herein desari This applicalion is made In cortvrliunca with San.lnactuin County Arrlinancv Na.r19 for sRwapo or Na. 1862 for weq/pump and ;q�l. ulat ions of the San Joaquin Local Hoalth Disg_ic� 7AL'HEAI;� L_04- L-04% at r1�t ` cep C� PERMIT��WPM O f Job'Add,oss �i City — Lot Size .1 • Owner's NamO Address �t� �,V+41 QQ pk,a,s� _ 440 ZZ-4; Contractor 1"JeCIe.IL A`� Addrrss t'� 11�__�License NO��_Phone64*. Isij TYPE OF WELL/PUMP: NEIN WELL U WELLREPLACEMENT' 0 DESTRUCTION L PUMP INSTALLATION U1 SYSTEM REPAIR U OTHER % Sip L. epV�o►gj DISTANCE TO NEAREST: SEPTIC TANK >1Sofi-A-_ SEWER LINES , DISPOSAL FLd2`1&--; OP, LINE >t i`1,=] Y ' FOUNDATION AGRICULTURE WELL�?�QQTHEft WELL li0 t'f'ITS/SUMPSf! INTENDED USE TYPE OF WELL PROOLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrlilt C3 opal) tiottom 0 Manteca Dia. of Wetl Excavation pia. of Well Casing Ll Oomeatlr. Prlvate L1 Gravel Pack lA Tracy Type of Casing _ Specifications N Public M Other 11 Dotta 000111 of Grout Seal p _ Type of {;rout I I irriliatinn _ Approx. Depth I I Easiarn Surface Seal Installed b Repair Work Dona I3 Type of Pump H.P. Stats Work Dune 7 Welt Destruction U Wall Diameter Sealing Material {top 50'1 Filler De th �. P a Material Ilielpw 50'1 TYPE or 5EF'1iC WDMR: NEW INSTAI.LATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sawar is a available will tin 200 Iasi.I Installation will servo; Rosidenre I Commercial— Other Number of living units: Number of bedrooms Q • Gharsclot Of suit to s depth of 3 feet: Water table dapth f SEPTIC TANK M Typo/Mfg Capacity No, Compartments PKK, TREATMENT PLT. I.) Method of Disposal a Distance to nearest; Well _ Foundation r o property Lina LEACHING LINE LI No. 6 Lettpth of linea __ _ Total kgngth/alta FILT£R BED C1 01stance:to nearest; Well Foundation+ .,_, Property Line r SEEPAGE PITS I I Depth .Size Number SUMPS 1.1 Dlsrance'to nearest: Well . Foundation properly Line — „4.�; DISPOSAL PONDS L� I hereby certify that I have propared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end F rules and regulations or the San Joaquln Local Health District. )tome owner Ur licunsud agent's signawre certifies the following; "I certify that in the perlolmanre of the work fol which this permit i9 issued. I shall not employ any person in Such manner a&16 became sub)acl to workman's compensation lawn of California." Contractor's hiring or suh-contracting signature Codifies the following: "I conity Ihat in the pertormanco of the walk lot which this parnlit is issued, I shall employ persons subject to workman's compansa- tion laws of California," t _•.' The applicant must crVor& inSpectinno, Complafe drawing on reverse side, Signed X Title: L � T,� Orate: n, FOR DEPARTMENT USE-ONLY ' Application Accopted byA _.VIP pat tt, C Area q Pit or Grout lospeotion by Data�,r�_ ____ Final Inspection by Date .,, Additlonal Comments: �. 0 5tk 488-6781 ❑ Lodi 3 •3621 O Ma lace 823-7104 CT Tracy 835-83$5 J. Applicant - Return all co41 ples. o: Environmental Health Permit/Sarvlcas 1601 la. Hazolton Ave„ P. Box Y Stit CA 5201 Az, FEE AMOUNT DUE I AMOUNT REMITTED K RECEIVED BY DATE PERMI7'No. k- INFO _. CASH Ov >'r.FH 14-n - f