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,43 '14 ;,.�fH',' n. USAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '{'YEAR FROM DATE ISSUED i (Complete in Triplicate) r � p� I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor h LdribtfQ �ppli tion is j nd the Ruleand ulatlons oan Joaquin I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump a g Local Health District. Jab Address 0 r � Ai)t•- � City Or+ QLot Size �p 1 PM Owner's Name 0 Address ¢ P e Phone Contractor qC1 G� Address w s r OL' _L cense No '30 5 7Z/ Phone D�✓1n3� R ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ; v EJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications „❑ Public Ll Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Seating Material (top 50') F Depth `Filler Material'(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIRIADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is l available within 200 feet.) 6 Installation will serve: Residence Commercial_ Other Number of living units: —J—' Number_,o bedrooms - Character of soil to a depth of 3 feet:" Water table depth- SEPTIC TANK ]R1 Type/Mfg Cooje_ Capacity lSQSJ No. Compartments PKG. TREATMENT PLT. ❑ ' f yj Method of D11posal Distance to nearest: Well _0 Foundation t Property fine f ,. LEACHING LINE i3'No. & Length of lines �� ff 961 Total length/size FILTER BED F' Distance to nearest: Well_: tom Foundation "70 1 Property Line 1 SEEPAGE PITS 1; pt Size Number fr SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS x ❑ I 1 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."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." The applicant must call for ll re fired inspections. Complete drawing on reverse side. Signed X /( T Title: Date: l 3� �I FOR DEPARTMENT USE ONLY Application Accepted nby ` Date I r Area �? I Pit or Grout Inspection by Data Final Inspection by Date 1/ K 7 r Additionat Comments: ' .7 O ❑ Stk 466-6781 ❑ Lod 0-3621 b Manteca 7104 d Tracy 836-6385 s gOff C?PS` .Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l � k FEE AMOUNT D1:UE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFO 7� D W j ♦ EH13-24 IREV,i/K 5i ` il'-J �,p 1 i EH 1 .28 1