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SAN JOAnUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466.6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p53 2 .7 91 0 (Complete in Triplicate) application is oa yin County Ordinance N 548 far sewage or No. 1862 for welllpump and the Rules and Reg_ula[rons of the San�laa4u'n M Application is he�ebv made to the San Joaquin Locaf Health District for a permit to construct andlor install the warkrHe�irSrd"e"stritred:I s fiance with San q made in comp 62 L/_U y C O Local Health District. J r J• o'o "YY —�y'"-�' ��ys•t PM -r 5' City II�Cir_ Lot Size 7 ec CJ Job Address i� !f�� /oQy IRS �/ 1 ��a^� Address f Dc[ j?`{rl.rs:n koa 7f ac Phone �--� ul v !� 7 Owner's Name 2,7199 1--;bei-- y L- ' L (.� ��✓f' License Na. r 3 Phone 1)11 Terrur�l GhYlar- 1,n �o ��'` � Contractor U/'rlli pESTRUCTION ❑ NEW WELL ❑ WELL REPLACEMENT ❑ ) TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ �O�T�H�Eii��f��hd�Ir1r7�S PUMP INSTALLATION p❑ �Ui 1'� DISPOSAL FLP. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK 4aDa 'T SEWERAGRICULTURE LINES 111 PITSISUMPS V� FOUNDATION �pOp •f' AGRICULTURE WEL�pTHER WELL TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. of Well Casing INTENDED USE Dia. of Well Excavation ❑ Open Bottom G Manteca Specifications Cl Industrial e of Casing ❑ Gravel 7yp Pack ❑ Tracy Type of Grout G DomesticlPrivate n Delta Depth of Grout Seal I"1 Public Cl Other —Approx. Depth l i Eastern Surface Seal installed by i I Irnyatian H P State Work Done , ` Repair Work Done U Type of Pump �--� Well Destruction ❑ Well Diameter -- Sealing Material (top 50'1 _ [ Filler Material (Below 50'} Depth sewer is ilable within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION available I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic systeM permuted if pub �. l� � Installation will serve: Residence Commercial Other r" 'r Number of living units: Number of bedrooms 1— Water table depth Character of soil to a depth of 3 feet: Capacity_� No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG, TREATMENT PLT. ❑ Foundation� Property Line l O Distance to nearest: Well 1� Total length!size LEACHING LINE . ❑ No. S Length of lines Propertll Line�-- FILTER HED E) Distance to nearest: Weil�— Foundation_ � Size Number SEEPAGE PITS I i Depth Property Line�--- U SUMPS L! Distance to nearest: Well Foundation�-- � r DISPOSAL PONDS ❑ I I hereby cerutY that I have prepared this application[and that the work will be done in accordance with San Joaquin c°unty ordinances, state laws, and rules and reguiahons of the San Joaquin Local Health Dribtnct' * tun eettifiM the foblymng: I certify that in the performance of the work for which this permit is issued. I shall not Home owner or licensed agent' S" to yeorkman's compensation laws of California." ContractO�ii�b t to workmang Of !sc mnature I employ,any person in such manner as to becorne subNot certifies the fallowing:"I c9f% Y that rn the pf>r(�r"of the 1Mo for which this permit is issued,I shall employ f� tion laws of California." a The applicant must call for all raguaed ins us. Complete drawing on reverse gide.Y J�J r/"J Data: r Title: Signed X F R DEPARTMENT U E ONLY ` Rate D Area Application Accepted by Final Inspection by Date Pit or Grout Inspection by Date. Additional Comments: ❑ Lodi 369.3621 0 M teca 823.7104 C] T 835-63 4 ❑ Stk 466-6781 to: Environmental Health permitlSen+icss 1601 E. Hazelton Ave., P.O. Applicant • Return all copies Box 2009. Stk., CA F x RECEIVED HY DATE PERMIT Nt1. ' FEE AMOUNT DUE AMOUNT AEmirr 0 1 INFO . EM 13-24(REV-tIA5) -3�• �� EH U42a i �.