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4 l -rJjw .,;, as s'oFf;k? ','fg r x '"' rraia4.v.:.1 F- '•.:,Y4+L a tilc.a.cq'+ti - �,� ,,�.,7a�,s/ Y{�yvia ( / ', «. ,k� y.-.' :� .r� t' l° .• s -'k �; •"•'�1'ii'•4"�, a^'Mrf$k cr� sn'ss. "�a.J ,rw?y � S�f'w-rlY`a�' s y�, y}g•{ yp�� .�r {f�a i APPLICATION F OR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT „: 'tee ' �<e 1601 E. HAZELTON AVE., STOCKTON, CA } * Telephone (209) 466-6781 ` � PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED 4 (Ccmpfete in Triplicate) Zi Application is hereby made to the San Joaquin local Health District for a permit to construet and/or install the work heroin descrlbed.`Thh spalkatlon Is smeas in compliance with Sen Joaquin County Ordinance No.549 for sewage or No.1862 for well/pu p and the Rules and Regulations of the San Joaquin ,( 4 Local Health District. Job Address12 !t�L City_ Lot Size Owner's Namely Address / li ram Phone C contractor � F Address DL!cense Phone No TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ rF PUMP INSTALLATION C SYSTEM REPAIR ❑ - OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP LINE T 1 FOUNDATION AGRICULTUPE WELL OTHER WELL__ PITS/SUMPS r rz "'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ 4 1 p}; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Will Excavation_ Dia.of,Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Cssin3 Specificatloro �z- L, Public ❑ Other ❑ Delta Depth of Grout Sea! Type of Grout t� t'' �j }✓# sa� ❑.Irrigation - L—Approx. Depth C2 Eastern - 'Surface Seal Ir,;;talled by_ ��` Re air Work Done ❑ T A ' #� p ype of Pump H.P- State Work Done > ! Well Destruction Q Well Diameter _ Sealing Materiri Itcp 501 Depth Filler Matorial (Below 50') r "r''t , •t FSS a i [' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPA,R/AODITION Ti( DESTRUCTION ❑ INo septic system permitted If public sewer r r� availabis within 200 feet.) { r-, Installation will serve: Resldence�---- Commercial. Other Number of living units — ro Number of bedoms Character of soil to a depth of 3 feet: i9>Tl 1/ r✓L Water table depth SEPTIC TANK= TYPe%Mfg capacity��C7, _ No. Compart"mr. 4 % ` PKU:TREATMENT PLT,u �~ T Method of Dispose) .C�f Jr 1 r t Cistance to nearest: Well�fS Foundation Property Line /e,/�7 r {{ LEACHING LINE ❑ No.b Length of lines Total length/size F LTER BED ❑ Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS 0 " Depth Size t^&=E!' Number SUMPS ❑ Distance to nearest: Well Fqundation Property Lina DISPOSAL PONDS ❑ I hereby certify.that!.have prepared this application and that the work will he done in accordance with San Joaquin county ordinances;state laws anti rules and regulations of the San Joaquin Local Health District. j �5 Home ovmer or licensed agent's signature certifies the following: "I certify thal,in!! pPrfo mance of the work for which this permit is issued,,)shall not'c employ any peruon in such manner as to become subject to workman's wrnpensation laws of California."Ccnt•aciors hiring or sub-contrectln^aignat ire>*" certifies the following: 'I certify that in the performance of the wore for which this permit is issued,I shall employ persons subject to workman s compenaa+q_ sh iq� tion laws of California - - - r' The\applicant must for all quirad'nspoe/diens. Complete drawing on reverse side. Signed Title: �..P / Date:'. t 9 D --�' �_ — ate ? t3A' p FOR DEPAn ENT USE ONLY �. A"ppGcation Accepted b a P Y — Date Area Qf� Pit or GrcJi'h4 i4ction by Date_ Final Inspection by Date Additional Comments::-I ;�C�r� C Stk 466-6781 C Lodi -369-3621 ❑ Manteca M-7104.. ❑ Tracy 8356385 Applicant-Return all copies!o: Ervironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bcr.2009, Sik., CA 95201 v ,; tts "tjt � NFO FEEAMOUNT DUE AMOUNTPEMITTED CASH RECEIVED Ry DATE PERMIT*No. , I;t EH t}N(REV.1re•1 EH 14 26 >"' '! Y,pX�'��rY.. � '.' tT ?4 + �= .?" t y �o�)rt�, t �CK �':..Y4 xKJ+�� ' f�-r�5 > •t� ��tt �,1 (�Y� '4''a¢t� �' a .J t r I- �< - K.'. i � t�7 1-r Yi-1Ey: Ptl''Yjpra''(•'�ysf� +. f� Y w�biy �:. �,•�.�".. �: ai'.4 '4`gj�'"•!'� l<11, •'.'h' N �'1' :�ib4l