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> SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hesehy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is 1, made in cornpiidnCe with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address City Loi Size PM I` J Owner's Name o lam/ Address u Q "r�/�l�p�e� , >?. I� � Phone r _ _ C� Contractor �� ' !!%`� /� ` Address_ c�r."bl 077 3 License fVo.�S/.�- '� 1 6 y�97 ,• �- .-- Phone ( TYPE OF WELL/PUMP: II NEW WELL i] WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.© DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack 13 Tracy Type of Casing" Specifications i'I Public i_1 Olther ❑ Delta Depth of Grout Seal Type at Grout _ I I Irrigation 11'Approx. Depth [ I Eastern Surface Seal Installed by f Repair Work Done L7 Type of Pump WP, State Work Dont _ Well Destruction ❑ Wel;.Diameter Sealing Material (top 50') r Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEII INSTALLATION , REPAIR/ADDITION I DESTRUCTION I I INo septic system permitted it public sewer is L I available within 200 feet.), . Installation will serve: Residence_ Commercial_z'Other Number of living units: -4 Number of bedrooms Character of soil to a depth !3 feet: A r Water table depth / 11 SEPTIC TANK T?ype/Mfg / Capacity No. Compartments PKG. TREATMENT PLT. ❑ IM Method of Disppsai t DMstance to nearest: Well 1��1 Foundations_ Ptoperty.Line l0 LEACHING LINE No. & Length of fines _f 01_ �Q_O Total length/size_� � FILTER BED ! r� ❑ Distance to nearest: Well Foundation ,�� /CL-r..__ Property Line� a SEEPAGE PITSDepth ,—0 Si,,, �� Number SUMPS 4 t LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count Joa I rules and regulations of the Sar0_10aquin Local Health District. 4 /ordinances, state laws, and Home owner or licensed agent's(signature certifies the following: "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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I!! The applicant st all for re M uir inspections. Complete drawing on rev side. i Signed X Title: pate: r 1ii ! FOR DEPARTMENT USE ONLY Application Accepted by Date -1� _ Area—ADL � Pit r Grout !ns coon b "v"� .1 / Q �7� 1. Date Final Inspection by Date f`l!' oVtnal Cafnment y, ❑ Stk 466-6781 odr ''369 ❑ Manteca 923-7104 ❑ Tracy 835-63$5 1 �a � Applicant- Return all Copies to: Environme tal Health Permit/Services 1 1 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 }� e ialig 9 Ft uc a 0 q a/ fa�.ks ..,5�a�/ems �JJII+f►lI!!� - «<///C�nn INFO FEE AMOUNT DUE AMOUN REMITTED CK RECEIVED 8Y CASH DATE PERMIT NO. i �.EH13-21tREV.tin51 - t � '~333) , . FH 14-M