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OSAN JO AQUIN LOCAL HEALTH DIST 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is" uleby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance 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. W 1-000-50 96 -_ S ANT- A X_N_RR i � City (AAW&. Lot Size��Z00 Ac„�r PM Job Address ,,••'' Owner's Name Address �/e Z G!/._� G f ' —--— -- Phone 0 M __ 7 � SV7 Phone Contractor L2XL/,m Address CST F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ 5viL i,J6S PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _ __ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,i CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications I'l Public (1 Other fl Delta Depth of Grout Seal ------ _ Type of Grout I I Irrigation _— Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done LI Type of Pump __ H.P. ._ State Work Done Well Destruction ❑ Well Diameter — _ Sealing Material (top 50'1 — — Depth __ Filler Material (Below 501 — --- ThPE OF SEPTIC WORK: NEW INSTALLATION I I RJ PAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation e: Residence_ Commercial __- Other — Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ -___ Water table depth i SEPTIC TANK Cl Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. C1 Method of Disposal ----- -- Distance to nearest: Well - Foun n _ — -. -- Property Line LEACHING LINE CI No. & Length of lines _ Total h/size______._. FILTER BED ❑ Distance to nearest: Well ____—__ Foundation Propert e SEEPAGE PITS I I Depth _Size __.____.__—_—__— __ Number - SUMPS L I Distance to nearest: Well ___.___ Foundation_ Property Line - - DISPOSAL PONDS 1-1 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, an rules and regulations of the San Joaquin Local Health District. 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." The applicant mu t call for all required inspections. Complete drawing on reverse side. p� Signed X _ _-_._____ Title: ._ep. ��_ L�E'n'77--1 Date: FOEPARTMENT USE ONLY i Application Accepted by _�� Date Area Pit or Grout Inspection by Date Final Inspection by _ - --_ Date Additional Comments: — ------ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED '/ (✓^�� --- . RECEIVED BY DATE �Pf{E�RM'.LIYT'N/JO . INFO 2a�N7 iF � d EH 13-24(REV.i 115l / EH 14-2d � (J 7�