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[;"I AY 2 4 ':,A1, APPLICA#T4ON;06R PERMIT �r C~ SAN JOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEATH NEE 1601 E. HAZErTON,AVE., STOCKTON, CA PERMITJSERVICES IF Teleph8nej(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 herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 7X D 12 City A0A-t1P4 Lot Size _�!4LO PM Owner's Name V .P a! R,Pd Address SQrs6 Phone Contractor FA-O ^n 6. Address 7 AAELB66T Ai'B License No. 4 ' Phone 7 TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST:;SEPT�C TANK - SEWER LINES, DISPOSAL FLD.1 PROP. LIN FOUNDATION �'�' AGRICULTURE.WELL OTHER WELL PITS/SUMPS u INTENDED USE TYPE OF WELLI PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r i Dialof Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of,Casings �__ 'Spatification§" FI Public ❑ Other ❑ Delta Depth roof Grout I t Type of Grout I I Irrigation —_Approx. Depth I I Eastern SuAa'ca Seat installed by - i Repair Work Done O Type of Pump H.P,.r` �� ! State Work Done_ Well Destruction El Well Diameter � ¢sling FMaterial (top 50'1 1 Depth .'..,,Filler-Mateflah(Below 501 ; - TYPE OFSEPTICWORK: NEW INSTALLATION I EPAIR/ADDITION X DESTRUCTION I I (No septic system permitted if public sewer is y - r m r� 4/ r available within 200 feel) Installation will serve: Residence_ Coercial_ Oth r R '/ j� �/��+ /J`,' )/' Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: dot Ab LB.am I i / Water table depth SEPTIC TANK '1 ❑ Type/Mfg K i S;7-1E Capacity No. Compartments PKG. TREATMENT PLT. ❑ �'. / Method of Disposal Distance to nearest: Well Foundation Property Line I � LEACHING LINE ,Q.I( No. & Length of lines 100 Total longth/si, ZOO� / .. / ;FILTER BED ❑ Distance to nearest: Well Foundation_ 40 PropertyLine ]S SE6AGE PITS l)( Depth Size = zr Number 8 SUMPS- ance to nearest: �Wall Foundation '7S Property Line 7S Property -- - ' _ _ I hereby certify that Ittiave prepared this application and that the work will bee-done in accordance with San Joaquin county" oidlnances, state laws, and rules and regulations of the San Joaquin Local Health District. -j" _..;Home owner or licensed agent's signature candies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any pifibifin'sa-cWmanrier as to become'subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"1 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_"- . T _. The applicaht must iallfBr all required inspections. Complete drawing on reDarse's!de. yy//Jf //JJ /J J Signed X�'�jGrnF+.a Title: &;C;W Date: F R DEPARTMENT USE ONLY (� Application Accepted by ,.��/ ..�{� M Data S Zp/�_q? Area I C! &or Grout Inspection by L a 9_Q-�'" Final Inspection by LzN Date 0" - Additional Comments: ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca &23-7104 El Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 z FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. INFO CASH m p EMhl2l IR" I,.