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N F riys n f APPLICATIO.i FOR ` PERMIT `Jh JOF()Li.', LOCAL HEALTH 31STRICi '.i01 E. HAlELION AVE.. STOCKTON. CA PERMIT NO. �. 7 Telephone (204) 466-6781 ��— !k1T F.PIPFISSUED , DATE ISSUED 1 J 5 11EAA FROM DATE ISSUED ! ' (Complatp in Triplicate) !;,titatiarl is hereby made to the San jt,_- X411:x,411 Health District for a permit to construct and/or Install the work herein' described, This aDDIICatIon is made in coalpliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/rump and the Rules and Regulations of the San Joaqu!n Local Health District. Job AddressSz.tl N Subdivision Name (� Owner's Name Address Phone w Contractor's Name mn License No. Z�t4'Zs;_ T Phone TYPE OF WELL PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION❑ �L PUMP INSIALLATTON C] SYSTEM REPAIR ❑ OTHER j� W=l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES UISPOSAL FLO. POOP. LiNE FOUIIGATION AGRICULTURE WELL OTHER WELL PiTS/SUMPS I '�1 ''! i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF{CATi0N5 ! ) 0 Industrial [J Open Bottom Manteca 01a, of Well Excavation {_(Domestic/Private 0 Gravel rackU Tracy Dia. of Well Casing !- t ublic ❑P _ G Other ❑Delta Type of Casing irrigation (.1Approx, ❑Eastern F [Cathodic Protection Depth Specifications jkI ^ ❑Geophysical Depth of Grout Seal f (D other Type of Grout Surface Seal Installed by Repair Mork Done Type of Pum H.P. [] D State Work Done ; t Well Destruction[] Well Diasxter Sealing Material (top 50'Q - 1 - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 1� Installation will serve: Residence _41S Commercial _ Other available within 200. feet.) { Number of living units: __L Number of bedrooms Z Lot size II Character of soil to a depth of 3 feet, Water table depth,4!L-Z, FSEPTIC TANK Type/Mfg 4+< Capacity -��p-- Trp, Compartments PKG. T1IEATMENT PLT. ❑ Type/Mfg .. Capacity Method OF Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line { ` DESTRUCTION ❑ LEACWING LIKE No. E Length of lines �^�� Total length/Size FILTER BED 0 Distance to nearest: Well Foundation �� Property Line SEEPAGE PITS 1W Depth -an - Size Number e suiPs ❑ Distance to nearest: Wei 1,L� Foundation "!, Property Line �AZ-�D DISPOSAL PONDS ❑ i 1 hereby certify that 1 have prepared this application and that the work will be done in atcordante with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local. Hearth District. Home owner or licensed agent's signature certifies the fDIICwIng! "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 workmanS compensation laws of California." p Contractor's hi ng or sub-contracting signet a certifies the following: "I certify that in the performance of the work for which this pe, is sued, f sh 11 empI rano- subject to worw n'S compenSatinn laws of California.", The appli a 1 f all r , ,' i thio s. Camp 'e nn reverse Side. Signed l Title: �� Date:1 �` F P ENI ISE DILLYr Application Accepted 4y _ Area U�T �tk 466-6781 • �} Additiunal Comments: Lodi 36g-3621 Pit or Grout lnspecti�n by - ✓/ _y�- Date /,/-�( 3' ��f Manteca 823-7104 r 2 ?0k,%.- Fir.,. Inspection by ' !_ )at e/�L�fr Cl TrdLy 835.6385 -a ..pDlicant Return alt copies to: Environmental Healtn/4er1n1t/dery ees 1601 E. Hazelton Ave.. PA. Box 2004. Stk.. CA 45201 l FEE I 835E A40U7i PUE AMOUhT RU!IT'EC T RECEIVED 8Y p„TE PERMf1 NO. i :tiFQ a l:+ I34: ;IV. 10/d2 10/62 500 t