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HI I IVHa1V � • V,a a � , . • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i City """ Lot Size PM Job Address ,t/ (�✓ (Si/44i Phone Owner's Name yr�C�j Q��/ ` r 1 Address �e - 4��''��"�[`/1/iA.Q/KL Phone Contractor L'S�O �J71/ Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ��•�� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9-- -Sc/1 LC.ic-/ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _(-7) FOUNDATION AGRICULTURE WELL -- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing Ll ❑Industrial Open Bottom El Manteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack 0 Tracy T of Grout_ — Fl Public ❑ Other 17 Delta Depth of Grout Seal Type I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 E OF SEPTIC WORK: NEW INSTALLATION I 1 111 PAIRrP.DDITION I DESTRUCTION 1 1 availabetrw within 200 permitted it public sewer is Installation will serve: side�e_ Commercial __ Other Number of living units: _ Numbe drooms Water table depth Character of soil to a depth of 9 f t Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg _ Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well _ Foundation Property Line LEACHING LINE ❑ No. & Length of lines -_ Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _-- Number SUMPS l Distance to nearest: Well _.—_- Foundation Property Line L DISPOSAL PONDS ❑ 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."Contractors hiring or sub-contracting signature certifies th@.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 an.plicanf rnu Z c II for all egUi 'ns pe rtIWls. Complete drawing on reverse side. LC-- e c ��"/� .J Title: Date: Signed X - — //— /` FOR DEPARTMENT USE ONLY Zs0 if ^N �O Area 7`� Application Accepted by t�/l`��l'b& -�� Data pa,;,; Pit or Grout Inspection by Final Inspection by Date- Additional Comments: ElStk 466.6781 ElLodi 369-3t2l ❑ Manteca 823-7104 ❑ Tr y 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED ��,y/[�/y�( .EM 13 14(REV.1/x51 ��. �, VV ^� EH 14-M