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- lip � a3 sdAp� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT. , ; _ 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone.{209} 466-6781 tV0�v•�-+,e:. PERMIT EXPIRES TYEAR FROM DATE ISSUED (Compiete.in Triplicate) " AppliCS66n is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worts heroin described Thls application: ' made in compliance with San Joaquin County Ordinance No.549 for.sewage or No.1862 for well/pup and the Rules and Regulations'of`Ihii'San Josgilirt zx Local Health Districtm.. - ,a e, aR {,�t,�`a '•-• -- # Job Address Q Citv ' Lot Site hi t( �f-L !� KJ 0U) �. 1 W. C.y'l r{D_r Owners Name_ Address� ... �. Phone # :`.:.Contractor- v ' d '" 'Y(ddress r / L icense No. CX ' Phone' TYPE OF WELL/PUMP. :.: ,NEW WELL C WELL REPLACEMENT 0 DESTRUCTION Q ��A £ PUMP INSTALLATIONZ'. SYSTEM REP 41f; Q OTHER !s DISTANGE TO NEAREST: SEPTIC TANK SEWER LINES-4 DISPOSAL FLD PROP.'LINE ' S ,ds FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS: cr C.lnduatnal 0 Open Bottom '' 0 Manteca Dia.of Well Excavation Dia of Well Casings " �r Q DornestiCJPrivatp 0 Gravel Pack p Tracy Type o1 Casing Speccstroru r ' 1'1 Public fi Other C7 Delta 'Depth of Grout Seat Type o!Grout - i;I.Irrigation x' " `Approx:.Depth +. I i Eastern Surface Seat tnstalled by Repak;Work.Done ❑,' Type of Pump:. H.P. State Work Done..,;:. - ... i A�gu_s Welt Destruction 0 Well Diameter Sealing Material Itop 50'1' I � r v Depth . Filter Material IBelow50'1. v+,f. x TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION [No sepliC system permitted it publk-feWQPlis. available within 2110 feet tnsta�atan v+6il serve Residence Commercial_ Other r Numtiar of living umta Number of bedrooms r - r Chi; acter of sol to a depth of 3 feM Water table depth < SEPTIC TANK .0 Tv"/Mfg Capacity No-Compartments' PKG TREATMENT PLT O Method of Disposal Destance to nearest: Well Foundation Property Line LEACHING LiNE' Ll No.I1 Length of lines Total length/size 'x FILTER BED } 0 Distanceto'nearest: Well Foundation -PropertyLirie'' SEEPAGE FITS ' IYI f Depth- Siie Number }� SUMPS" , Ll Distance to nearest: Wall 'Foundation Property Una DISPOSAL PONDS, D + r 1 t:eraby car eHythat 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordrnenca;,state Iarvs;iiiA rules and ragulatbnsbf the:San Joaquin Local Health District a Homeowner or licensed agent's signature certifies the Iollowing."I certify that in the performance of the work for which this permtit is isetted:7 a1taR rsot x ernploy any person in such rtrpnner as.to become subject to workmen':compensation laws of California."Gantrrctals hiring roc sub-coiiiractktp siptglue s callifresYhe following -'1 certify that in the performance of the work far which this permit is issued,I shall employ persons sut to workmanfi ' F R3 n; tion laMls of da►Itee e e€ r- Fie r Wt t, The appy m at for y ►eq a inspections Complete drawing an reverse side: ' " Signed Title �:_iianr... _ nate �•. .".4-�'ffi nl� �'' r n _ +.. .: ,_:- - r•' I *'mss•+- �) USE O VLY § ' AppHcatlan Accepted197r f--� e Date Z b Arps f" :. 471 Pet or Grout In:pectecn by Date Final Inspection by p + r §F �) !- Additional Coen mmts l7 ,an,jMr � C n T�G�! «"C-c LJ s -x Mfr :k_46&6781'; 0 Lode VM3UI "'O Manteca 823.7704ff Tracy 8 6385 ,, Y t �y ' Applicant Rstum all copies to:Environmental Health'Permit/Services 160111.Hazelton Ave..'P.O. Box 2009 Stk CA 95201' { FEE AMOUNT DUE AMOUNT REMITTED RECEIVED HY DATE," PERMIT'NO.. a c s INFO f.H'13-24 f42a 111EVrinbl (� Taw ; ras•BQtrA�'yyp 3^ 1w1.a �iiK rr'�'S". 4a- g Y ��AA'' F Com" U7•