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SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address02 E• 6 r".:�,r\fl I rte d. City <. Lot Size PM RSM sly �� 2°9. y'>{3-556 s 8 Owner' Name ra-(.1 f tG 60's Q.11�Elecfr+*(Addrass 1yo� Etj I:SQA • Fr�GSrfta CA P S.� e D 9`!520 _ ylS, !} 67I -Z5B Contractor Address Su bkq �YIGa (cense No, 37 3y3 Phone TYPE OF WELL/PUMP: NEWWELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t� FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 45 Dia. of Welt Casing bA Domestic/Privc,��$R Gravel Pack 9 Tracy Type of Casing PVC _ _. Specifications �pp Reza I'1 Public 11 Other 171 Delta Depth of Grout Seal -��eCA- Type of Grout C1 + beicL- I I trntlabon 2S--3Q Approx. Depth t I Eastern Surface Seal Installed by 6r,,At, te'a .'liyw b� Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction IJ Well Diameter Searing Material Itop 50'1 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION I I Wo septic system permitted if public sewer is available within 200 feat.! Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [7 Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE 1-1 No. 8 Length of lines Total length/size FILTER BED 11 Distance to nearest: Well-_ Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS I i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I I I hereby cenity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state 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 which this permit is issued, I shall no 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 cenity 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." flf 1 f l 1 t✓. e-( G c3��pf �-�r �Pr 11",J •�� ') The applicant cast call for all r wired inspections. Complete drawing on reverse side. --� Signed X _ Title: IM64-1 w 3 r♦ r n c• 'r+r Date: FOR DEPARTMENT USE ONLY J p ditZ' (J Application Accepted by t Area Pit or Grout Inspection byDal tion bate IN Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 966201 } FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO �r •. Ett 13.2 (REV.I n v 7 _ -- .-, ... _ .. ... .r.. -:.m.1 _R're^r-7"'.-_... 'F%:'F^^."'�:... .. _ ."t/! ... e ,_... -. ... - .e:---"- � ..•mss :.,-. _ _�-