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+- SAN iOAO,UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE-%ON AVE., STOGKTON, CA 6, r <br /> 'Telephone1209) 466P6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE.ISSUED �f� yt. r- '� <br /> (CoiTlplete in Triplicate) 4 Mn <br /> �y ,�y , •,.f f pS3. .g licatfon is <br /> Ith i Application is hefeby made to the San Joaquin rLocal <br /> Cance No.District549 for sewage or permit to <br /> 1862 forcwell and/orinstall <br /> atnd the Rules and herein <br /> Regulations of the pan Joaquin <br /> made in compliance with San Joaquin county <br /> Local Health District.' <br /> t1a'1 S City t Site PM <br /> alrow <br /> Job Address <br /> Phone <br /> -Address <br /> Owner's Nar4�aU4"k-11 <br /> [cense No. 3 6 l—) Phone <br /> Contractor rAddress <br /> NEW WELL O %WELL REPLACEMENT ❑ f! ( DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: OTHER ❑ ( n <br /> 1`--" SYSTEMi EPAIR ❑ v <br /> PUMP INSTALLATION El <br /> SEWER LINES _�— DISPOSAL FLD. PROP, UNE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF;WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .Ota. of Well Casing , <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation j Specifications <br /> Type of Casing <br /> 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> [3 Public ❑ Other LI Delta ' <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by , <br /> ° State Work Done <br /> f Repair Work Done [IH P Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 ►. <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIKIADDITION ❑, DESTRUCTION (No septic system <br /> m rented if public sewer is <br /> ava( Installation will serve: Residence` Commercial—: Other; <br /> 1 ; <br /> Number of living units: Number of bedrooms Water table depth. <br /> Character of soil to a depth of 3 feet: ,' No. Compartments <br /> SEPTIC TANK X. Type/Mfg Capacity . , 4 <br /> + Method'of Disposal <br /> k4 PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well } Foundation P,rgpbrty line <br /> LEACHING LINE ❑ • No. <br /> - - <br /> Length of lines '-�,..y Total-length/sizey" <br /> � & <br /> I FILTER BED ❑ Distance to nearest: Well Foundation �` 'Property;Line <br /> s <br /> SEEPAGE PITS r Depth( M Size eOre <br /> Number <br /> SUMPS ❑ Distance to nearest: Well 1 Foundation Property Line <br /> DISPOSAL PONDS Q, 'r # <br /> I hereby certify that I have prepared[this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> Y rules and regulations of the San Joaquin Local Health District. . , <br /> Home owner or licensed agent's signature certifies the following: 's l certify that in the performance of the work:for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman'sem compensation-laws Calif ornia.�Contrector's hiring'or sub contracting signature <br /> certifies the following: "I certify that r'whfch thWpermit.is.;ssued,I shall employ persons subject to workman's compensa- <br /> in the performance of the worlPfo <br /> I tion laws of California." <br /> The applicant u call for all equked inspections. Complete drawing on reverse side. /- <br /> I 1 Title: Date: ( <br /> Signed X <br /> t Ml FO-DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> ` [_ <br /> Pit or Grout Inspection by <br /> Date Final Inspection'by " <br /> Additional Comments.. <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca. 823-7104 r-�..❑ Tracy 635.6385 <br /> Applicant- Return all copies to: 6vironmental Health P-. it/Sere es 1601 E..Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT,REMITTED RECEIVED BY GATE PERMIT NO. 1 <br /> INFO <br /> REV <br /> + EH 73-245 .I i A's� '- i:"' <br /> EH 1428 <br /> t _ <br />