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MONT- PUBLIC HEALTH SERVICES � is SAH `JOAAUIN COUNTY P. O. Box 2009 ;F (1601 East Hazelton Avenue) I ,a ( ;11 Stockton, California 95201 -P �- PERMIT EXPIRES 1 YEAR FROM DATE 1ply (Complete in Triplicate) ADMICetiOn is hetaby made to the San Joaquin Local Has" District for a permit to construct and!or install the work herein ditscrlI)ad, This application is made in compliance with San Joaquin County Ordinance No. 549 tur sewage.or No. 1062 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. j Job Address { i �''LU�'� �G.C�lci vho City ._ Lot size :I PM r Owner's Nene nr I �`- Address 1�U� cv? 1N• S'' �CPhone ••6-Yf/-o lcof i Contractor.`�`� f4-k—Zus,%J i��^' Adtlress -�•'3 3 z�c� I.Ieanse No SS'f-GAS Pltone ►�`�3�-7 Z7b TYPE OF WELL/PUMP: NEW WELL 5a WELL REPLACEMENT CJ DESTRUCTION t;,] i•/�� PUMP INSTALLATION I`j SYSTEM REPAIR ❑ OTHER ®Se; L&rrNc.6 ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, )PROP. LINE .. 1 FOUNDATION AGRICULTURE WELL. _ OTHER WELL 'I PiTS/SUMPS , INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS i r D industrial ❑ Open Bottom 1-1 Manteca Die, of Well Excavation r— Dia. of Welf'Casing 3 Domestic/Private 0 Gravel Rack 17 Tracy Type of Casing Q V L Specifitadons' 'j .r 11 Public iX Other M." 1 1 Della Depth of Grout Seal 2� tn_S•�; �cC Type of GrotiC •ar rtu�. I I Irrigation 4.�jAplvox. Depth_ I I Eastorn Surface Soul Installed by Repair Work Done U Type of Pump H.p.". .., State Work Done Well Destruction ❑ Well Diameter Scaling Material (top 50') Depth Pi11er Material l8elow 50'i _ • " __ .i tr TYPE OF SEPTIC WORK: NEW INSTALLATION I I AM"AinirADDITION ; I DESTRUCTION I I iNo septic system permitted if public sower , is available within 20o feet.1 Installation wail serve, Residence_ Commercial__ Other Number of living units: Numbor of bedrooms _ l Character of soil to a depth of 3 feet: Y Water table depth SEPTIC TANK G7 Type/Mfg -, capacityNo. Compartments it r PKG. TREATMENT PLT.C7 Method of Disposal tj " Distance to nearest: Well Foundation. Property tine ;i I LEACHING LINE M No. 8 Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth , Sita __ SUMPS LI Distance to nearest: Well �.�.R — Number Foundation_�� Property Lime_ DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the Work will 1) j rules and regulations of the San Jsevum Local Health Di§rriet, ?done in accordance with San Joaquin county ordinances, atsie laws, and E! Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this Permit is issued, f shall not employ any person in such manner as to become subject to wurkman's compensation laws of California." Contractor's hiring or subcontracting signature s. certifies the fCali(o "I certify that in the Performance of the work f Califo tion lawn of rninia." or which this permit is issued,I shall employ persons subject to workman's compensa. The applicant must call tor all r aired inspections. Complete dravring on reverse side. signed x - 1• �� u _ Data: FOR DEPARTMENT USE ONLY i Application Accepted by j " Date i Pit Ar Gro inspection by - ! ; �3 C gra r A Final Inspection b y Additional Comments: ❑ Stk 466.Ml 0 Lodi 369-3621 L{'t ❑ Manteca 823.7104 ❑ Tracy 835-8395 tf Applicant • Return alt copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA°95201 FEE INFO AMOUNT DUE 4rtSOUNT REMITTED CASH RECEIVED gY �� CAT E j PERMITNO. • EH 73.24(REV.rr n., EH ta•7a � � ! .; I� T ,I ,r