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Y"X, Ai'PLIC«TI09 FOP. PERMIT SAN JOAN;N LOCAL HEkLTH,DISTRICT 1601 E. HAZELlOh r,YE . STOCKTON. CA PERMIT N0. �� "��flC% '$ Telephone (209) 466-6781 GATE ISSUED O�$3 PERMIT EXPIRES 1 NEAR FROM DATE ISSUED i (Complete in Triplicate] ¢ Application is hereby made to the San Joaquf% Local Health CSSLritt for a permit to Construct AnL/or install the 62 herein described. This application is made in compliance with San Joaquin county Ordinance No. 549 for sewage Or No. 18fi2 for�n+Nllpuep., and the Ruies and R ul i s of .he San in=a wealth District. . * bdivision Name ( Job Address ! r Address t-' e Owner Shame- Phar! 0 + icense No. k s Contractor's Na W TYPE OF WELL/PUFIP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ � 'a pUyp INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U ;0' ( ,t a SEWER LINES DISPOSAL-FLD. ; PROP. LINE A DISTANCE TO NEAREST: SE.TIC TANK --��— i FOUNDATION _AGRICULTURE WELL OTHER WELL PITS/SUMPS 5` t - a INTENDER USE TYPE OF YELL PROBLEM AREA CONSTRUG :.ECIFICATiI%tS Industrial ❑open Bottom [ Manteca -Cia. of Well Excavation Dia, of Well Casing ' r-'� • h: , T ; � ' ❑Doiaestic/Private ❑Gravel ,Pack Tracy r �M`y Public f ._ G Other ❑Delta Type of Casing - 5 tr lrri tion; Approx. ❑East2rtn Specificati ` ons ©Cdthodic.Proteetion. Depth Depth of Grout Seat '' f4 j A� ' ❑Geq*ysiul R Type of Grout f9'F^ ]OtherX %' Surface Seal�lnstalled by1 H.P. Work DonE a .. K : State k Repair'York Done❑ Type of:?unP. p �hjFWellOestnvction❑ "4k.T Dlaweter Sealing Material (top 50')` Filler Material (8--low 50') r'; � Depth _ - m REPAIlVADOITiON . (No septic tank or Seepage pit-permitted if public 'u ,TYPE OF St`PTIC WORK. NEW INSTALLATION (� available Within 2LYiateet } +r» ' l.•I Yr .. �.� ii��.•Y ixr 4�. Irstallat4ion xi11 SerYE ResidenceCommercial - Other _ Y �r Kummer Of noRa Lot's ize ` livabeP of living units i Yater table depths ►Character of soil•to a depth of 3 f x. ^ COW", rd. Capacity /.D C7ev 1 1,No• trtnts i � SEPTI_C Ti111K iJ Type/Mfg City a MEthod of 01spvs�l' °PKG."TREATMENT PLT. ❑ :Type/Mfg Capacity aSEWAGE F Foundation �Pra rest: WellSYSTEM �,.Ditance to nea , fio DESTRUCTION: ir� t r LEACHING LINE"a ,. : No. a Length of lines Total lfngth/size.` Fovrrdation 1L� Pr°pertyiLine � * i FILTER $ED : Distance to r+earest: Well x Size ;. i4 SEEPAGftPIT5 i Depth Nuober 'r,' Fomdation' � ProPef'ly Line SUMPS U Otsta,ke to neamt: cells r l r`.��i��D i DISPOSAL,PDNDS '$: ..[.1 •. i , S hereby Certify that ],have Drepared this application and that the wort will be done in accordance with San Joaav n_county F ;ordinance, Estate laws.,and rules.and regulations Of the San Joaquin Local Health District r ? ra Nage owner or licensed agent's signature certifies the falioring:'"I certify that in the perforannte ofaih�W'&W"f.CeNfornia." Imr t aCpemltctar1s fnldii 1 ortsub-cantra]ctlnansign turescartlfiesn such ntfiE fvllowr as to ln�Iscert fyect tthat iintha��arsrnce of the work far wh1Ch EyF ' F this petor's s• issued. 1 shall eaploy persons subject to workrun's CmPe+lsation laws of Callfomia.' k ' The appl.ica must 1 f -all required inspections• Complete drawing a everse,side 4S F� 1 Title. ' Date rtj t, v Signed 1( F0 fi EN7 USE ONLY ^ Stk 466-6731 App tion Accepted ,t • ._ Arid T� /yq Lodi 369-3521 q, a t ,n r Additional CaeeKnts. ❑ nteca 823-7104 ; . Date_ Pit or Grout inspection. 0,Tracy 835.6785 , ,•'s` ' Dat:.s �.� final,.Inspection by '� Applicant.=.Return all_Cop t Envi one*nta Health FerflitlServi.-r 1501 E. Haieitan Ave.. P.O.:Box 2009. 5tk CA 95201 a �RECEIVED SY DATE PERMIT NO. r FEEBASE. AMOUNT DUE AMOUNT REMITTi'O• .: i r ¢ �. - 5• �2 S? 10/82 $00 , x n FM 17 24 '. RE',. a 14-26 w `y ,r r.. lt;� P Tt _' 6A, -.r.'�' I �i ; .'� �'�'. �-