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„�,.--. � i•.rru�..,1 tvry rvr, rcr,rvlr t f �J JOAQUIN LOCAL HEALTH DISTRI, 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 4166 - 314;20 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 appt.,.ation 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. ^t_ Job Address City Lot Size PM Owner's Name S nl )(--1 Address Z N N. (2A/X-M.4 .Sur Pho •5: -197- A Contract _ er�m L Address ' License No Phon(; '"$/r TYPE OF E_L_L/PUMP: NEW WELLS59 7 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION TSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 500 SEWER LINES /0D��1- DISPOSAL FLI��{""PROP. LINE _t:K7 FOUNDATION �� AGRICULTURE WELL:!�� tO OTHER WELL�PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing E4 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications U Public 54 Other~ fA Delta Depth of Grout Seal -C-:.A) Type of Grout i rl Irrigation /sL21t Approx. Dep I I Eastern Surface Seat Installed by Repair Work Done fJ Type of Pump _.— H.P. __.I, _ State Work Done_ Well Destruction 1 , Well Diameter _ _ Sealing Material (top 501 Depth Filler Material 18elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence -_. Commercial -- Other Number of Irving units: _ Number of bedrooms _ Character of sod to a depth of 3 feet: ..__ _ ._ Water table depth SEPTIC TANK Ll Type/Mfg _- - _ - _ Capacity No. Compartments PKG. TREATMENT PLT L! Method of Disposal Distance to nearest. Well Foundation Property Linn-,A4 ,' ---- --- - — - -- -- - --- F2 E e � — LEACHING LINE 1 1 No. 8 Length of lines _ __. Total length/size FILTER BED I I Distance to nearest. Well __ ._ Foundation Property SEEPAGE PITS I I Depth — _ Site Number SUMPS 1 l Distance to nearest Well _ Foundation _ Property �A� NEA�1ty DISPOSAL PONDS t 1 �ES 1 hereby certify that 1 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 arty person in such manner as to become sublect to workman's compensation laws of California.”Contractors hiring or sub-contracting signature certifies the following: "I 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 - The applica tt st all for I required in etions Complete drawing o averse side. ,l �� Signed Xyl%� �v /t'� c .- - -- Title: 49 trC�� C! ~ 4�i pate: FOR DEPARTMENT USE ONLY Application Accepted by ( T1�-�— Date 613kIE, Area Pit or Grout Inspection by __. Date Final Inspection by Date Additional Comments: ❑ Stk 466.6781 O Lodi 369-3621 O Manteca 823-7104 O Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,FEE ti 0 O INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT O. EM 13-24(REV 1,w Sr EH 14 A -