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SAN JOAQUIN LOCAL HEALTH DISTRICI" 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ". " _;,LT`I (Complete in Triplicate) Application is hereby 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. 1 �' ��/n�'�� ^�/.�!� Job Address �„ E—`l�/�ot �.�1r4C V CityTRS Lot Size PM 'I Owner's Name 17t''F 1"n 5 e S OP fl C y Phone ZO 8 S S l Contractor B-� - G Address I/I/ 3F X11 r/3f� Sf-� [eM-icense No. T/Fi ? Phone 6S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTH ERA Sort Rag)NGS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing N ❑ Dpmestic/Private ❑ Gravel Pack 'Tracy Type of Casing Specifications U?�_ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal < 1 S reC Il' Type of Grout [ ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by O Repair Work Done ❑ Type of Pump H.P. State Work Done O Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NE INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑,Me,septic system permitted if public sewer s i available within 200 feet.) Installation will serve: Resident Commercial_ Other Number of living units: Nu ber of bedrooms Character of soil to a depth of 3 feet: / Water table depth - /aci No. Com aliments SEPTIC TANK ❑ Type/Mfg t.aP tl' p PKG. TREATMENT PLT. ❑ Method of Disposal Distance to ne est: Wel _ Foundation Property Line LEACHING LINE ❑ No. & Length of lutes Total length/size FILTER BED ❑ Distance to nearest: 1 Foundation Property Line SEEPAGE PITS ❑ Depth ize Number SUMPS ❑ Distance to arest: 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 San Joaquin county ordinaIceste taws, 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 is itr� id 1 shall notemploy any person in such manner as to become subject to workman's compensation laws of California.”Co iri ing signaturecertifies the following: "I certify that in the performance of the work for which this permit is issued, I shall emp su c ws canpen-J tion laws of California." \\�tJ; The applicaRj(�must cal for all required inspections. Complete drawing on reverse side. p SignedX II r04( C ✓I ('.-r Title: woo yZn ^C �tic(a<__ Date: 3I1� I� % F•,� kFe/iec� /' D)2�GPo �y5i�7' v OR DEPARTMENT USE ONLY Application Accepted by �iz�V "" Date Area �2— Q Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Slit 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83E5-6385 Applicant- Return all copies to: Environmental Health Permit/Services IBM E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED ASH RECEIVED By DATE PERMIT N0. INFO ` �}�� (} EH 13"24(REV.1/e 5) ,,h 1�J� 1% `t/v JC y y_3��7 EH 1426 O1 V J J 11