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SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work It6r'Pj "desCr'bed. This applicatign is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules andt L�a(ias Qjt�tpjSnL�oaquin Local Health District. ,,,,, AAA—c 502 East Grantline Rd. r;.., Tracv I „• c;, pna I hereby certity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 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." 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 shalt employ persons subject to workman's compensa- tion laws of California." The applicant t call for all required inspections. Complete drawing on r verse side. Signed X ✓; ('_ v� �---�/" Title: I S+ Date: 1®_D19,Avlr ` 0 f'I Z-a4lon ! e-fk- - Tof—S� DEPARTMEf USE ONLY/,z^/'8?©dit� ( An so/) Application Accepted by c ' � � Date !� � 'a a Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ SIR 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EH 13.24 (REV. 1/95 EH 14.28 INFO AMOUNT DUE 16th Floor Pacific Gas & Electric Owner's Name - Address 1 California, San Francisco, CA Phone (415)972-7095 Contractor N/A f %`' L '_ NSA NSA N/A GCASH Aii'dress License No. Phone TYPE OF WELL/PUMP: NEW WELL fX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Y(Mo lYbtN, VJEU_ 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 Ort Dia. of Well Excavation 8 Dia. of Well Casing X Domestic/ Private X Tracy Type of Casing SCh 40 PVC Specifications f"1 PublicOther rd 11 Delta Depth of Grout Seal 4 feet Type of Grout cement ben . 1 1 Irrigation 7QftApprox. Depth I I Eastern Surface Seal Installed by Pacific Gas & Electric Co. _ Repair Work Done (I Type of Pump N.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS 1.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 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." 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 shalt employ persons subject to workman's compensa- tion laws of California." The applicant t call for all required inspections. Complete drawing on r verse side. Signed X ✓; ('_ v� �---�/" Title: I S+ Date: 1®_D19,Avlr ` 0 f'I Z-a4lon ! e-fk- - Tof—S� DEPARTMEf USE ONLY/,z^/'8?©dit� ( An so/) Application Accepted by c ' � � Date !� � 'a a Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ SIR 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EH 13.24 (REV. 1/95 EH 14.28 INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMjIT�NO. GCASH qo �