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. - QUIN LOCAL HEALTH-DISTRI " ...__.,. ..- - SAN JOA 1601 E. HAZep�ona AVre..Tel09) 466-6781-TOCKTON, CA PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete in Triplicate) This applkatxm is Local Health District for a permit to eonstrwet and/or p1StaN the work(brain Regulations of 111e San Joaquin Application is t,ereby Me&- -the Stln.lOs4tNn or No. 1862 for weltlpump and the Rubs and Aeg mads in compliance with Son Joa�uIV Ordinance No.549 for sewage Local Health District. �' City t.Aaar�rfs-_ Lot Size t�rei:ZOdr PM r< Job Address 99 � Yf�s -- - SCA -Z7 Phone ' — Address �w"am04 A 6?dOwners Na;Mj -!'t Address O• License No.�_—�phoneContractor DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ p6S c,'�> PUMP INSTALLATION 13SYSTEM REPAIR ❑ OTHER —+ate DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- DISPO AL FLO. PRWtM FOUNDATION AGRICULTURE WELL OTHE. ELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR NSTRUCTION SPECIFI TIONS O Irttlttstriat ❑ Open Bottom ❑ Manteca I Excavation Dia.of Well Casing Specifications Tracy CasiSpecifications❑Domestic/Private ❑ Gravel Pack Type of G t ❑ Public f_ 1 Other to th of Grout Seal ---I I I Irrigation _ l I E Surface Seal Inst by ' Repair Work Done 0 Type ump t Done Wor Well Destruction ❑ Well ter Sea ng Material It Depth !ft, Material(BeloWl TYPE OF SEPTIC WORK: NEW I ALLATION I REPA ADDITION I I STR tted rf public sewer n IftaNation wiN serve: Residence _ al_ Other Number of living units: Number s n depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mf9 qty -NVIROFA t�l PKG. TREATMENT PLT.❑ FM RaWMICE.Sr__� Distance to Well F ation vP�w'a LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Wen _ Foundation Property Line SEEPAGE PITS 11 Depth Size —_ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances,state laws, and rubs and regulations of the San Joaquin Local Health Dtibtrict. 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 parson[in such manner as to become subject to workman's compensation laws of California."Contractors 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." Thsapoivgtf �Or ,�equired inspections. Complete drawing on reverse side. Sigma — Title: [ Date: 7- LZ-,Tgy FOR DEPARTMENT USE ONLY p f Date Area Application Accepted by — - a r� Pit or Grout inspection by Date Final Inspection by Data Additional Conwnents: ❑Stk 4064MI O Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Appleent- Return all copies to: Environmental Health Pernat/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 96201 ' AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. FEE INFO G ♦EH 13-31(REV.1/h 411 I p� EH 14-M •.�s�: .aa�w:,..9._•_y±...r !'.ws�;r{i'A":.'.. .. �..#'_�'�.... ..�. ..s.»Y7¢�;*!""� ... -. ..... ... _.. .... . .t_ . . ... .....a-i,. .. _ .