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run rtrtivi lG SAN JOAQUIN LOCAL HEALTH DISTRIC 1 1 E. HAZEL T ON A KTON, CA p p►K M V Ep Telepholie (209) 466-6781 REGEI SAN JOAQUIN LOCAL HEALTH 9 EXPIRES 1 YEAR FROM DATE ISSUED 1� egad ENVIRONMENTAL HEALTH UI (Complete in Triplicate) SEECIAL PERMIT NQV H Application is reby made to the San Joaquin Local Health District for a permit to construct and/or install the worvalolist �CA�T made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and ttm s application is Local Health District. a San Joaquin /� pp Job Address �-kA-y- `� ✓ City Lot Size�'Ov CACrG5 PM Owner's Name iLr _VV al� C2 Ybt j Address �1 D")� Ir^1l �/,� J uG 4'APhone — Contractor Tt'Xr inr4 Address er 1-4 s.lvtucense No.qA2125 U Phone U TYPE OF WELL/PUMP: NE ELL X WELL FtEPLACEMENT ❑ 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 �11 d 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing a Domestic/Private L, r Gravel Pack El Type of Casing�I'1. P��^ Specifications 1"1 Public n Other F1 Delta Depth of Grout Seal Type of GroutTU� l<\,�►•I1 1t; I' — I I Irrigationy Approx. Depth I I Eastern Surface Seal installed by M I— V^ 1 (1 F Repair Work Done ❑ Type of Pump _ H.P. State Work Done_ Well Destruction O Well Diameterj �— Sealing Material (top 50'1 Depth -1/ r — Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAfR/ADDITION 1 I DESTRUCTION 1 1 (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size_ Number SUMPS 1_1 Distance to nearest: Well Foundation - Property Line DISPOSAL PONOS ❑ 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 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."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thispermit is issued, tion laws of California." �9C'F1�'QR91�nEE9'�9�tWEP(�TP1'{ I�(�sa The applicant st call for all required ins ENVIRONMENTAL HEALTH DIS/ISION ions. Complete drawing on side. SPECIAL Signed X Title: �1 ��l O A I at - �-J Oate: FOR DEPARTMENT USE ONLY rl Application Accepted by _ _ Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: O Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835.63M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bou 2009, Stk.,CA 95201 FEE AMOUNT DUE AMOUNT REMRTEO K INFO CASH RECEIVED BY DATE PERMIT-NO. •.EH 1124(REV.V w 51 EH 14-26