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16011 HAZEL T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVE p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) OCT 18 1988 Application is he)eby made to the Sari Joaquin Local Health District for a permit to construct and/or install t ereinnrd�e'scribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and t*�r�NrpXn1#Atr$@n Joaquin Local Health District. �.� / PERMIT/SERVICES��It143_020— Job Address a 15 0 �Y. C h a r�e Y' Wet V City��1 Lot Size %3 *S ctCk- PM 0/1 Owner's Name FQ r C/ /Y E'W )q0Address ��-�O W. CA d-z wQ N Phone`2°9J ContractorMdAeW8W1 is fta, Address 01011 sttr�a'x •A=*o i�icense No. u«P�o6 63896 TYPE OF WELL/PUMP: NEW WELL , WELL REPLACEMENT ❑ DESTRUCTION ❑ ` nnnccc�ss PUMP INSTALLATION O SYSTEM REPAIR ❑ �O,T�,H�E�R DISTANCE TO NEAREST: SEPTIC TANK y'/0 SEWER LINES oo/ DISPOSAL FLO. PROP. LINE FOUNDATION `T Q/ AGRICULTURE WELL>/Soo/ OTHER WELL dC / PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation 7" Dia. of Well Casing 2 >6lDernestic/Private X Gravel Pack ❑ Tracy Type of Casing ScA. �0 f Specifications f FI Public D Other n 1s'« Delta Depth of Grout Seal rl2 �� Type of Grout LC� _ 1 I Irrigation Snn[+-b"vrh E'-cl21C37afio>1 _ g- ��.Approx. Depth l I Eastern Surface Seal Installed by,-r, Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 1 (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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of'Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 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 fo wing: "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 Cali ornia." The appli t us call ora quit i s ns..Complete drawing on reverse side. Signed X Title: 5k'C. zuor{,sf Date: t rrZ Sn 3L CS V— FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. INFO CASH ♦ EH 13.24(REV.rix s) EH 14-26