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:SA' -JOAQliIN11 OOAL HEALTH DISTRICT �>? 1601 E. HAZFL.TQN AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR TROM DATE ISSUED (Complete in`Triplicate? TILE -COPY'C o P Y " 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 Rylesand Regulations of the San Joaquin ! Local Health DiArict. _ Job Address ^ / 1 City Lot Size PM Owner's Name. 17P rr^�r ` Address _ 6 _ Ya Phone- , Contractor 1 Address License No. Phone J 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ DomemWPrivate ❑ Gravel Pack ❑Tracy Type of Casin Specifications ❑ Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout \` ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by,• Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ftop 50'} Depth Filler Material (Below 5(Y} r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑' REPAIR/ADDITION ❑ DESTRUCTIOP (No se trc m i� p syste- p8rrriitted if public sewer is available within?W'feet.l # Installation will serve: Residence_ Commercial— Other Number of living'units: Number of bedrooms h Character of loll to a-depth.of 3 feet: Water table depth SEPTIC TANK1-1 !] Type/Mfg Capacity ' No. Compartments I PKG. TREATMENT PLT'."❑ £ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No:& Le th of lines } ng Total length/size FILTER BED ❑ Distance to nearest:. Well Foundation Property.Line SEEPAGE PITS ❑ Depth Size Number it SUMPS 0 Distance to nearest: Well w 'Foundatlan Property Une DISPOSAL PONDS ❑ i 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.'ageWs signhtute caitif s the following:?'I certify that in the performance of the work for which this perrnit is issued, 1 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 thaguft ormance of thework for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws o Ii mia."The appy m ust for all tions. Complete drawing on reverse side. % Signed T �� _7 VW Date: FOR f)EPAR ENT USE ONLY l 1 ' Application Accepted by Date. f � Area �+ Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 4664MI Ij Lodi 3W3621 0,Manteca 823-7104 ❑ Tracy ..835-6385 Applicant- Return all copies to- Environmental Health Permft/Services 1601E Hazelton Ave.,'P.O.Box 2009,.Stk., CA 95201 FEEL INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY - DATE PERMIT NQ. +EH t3-24(REV.1/8 5) 17L') H 14