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k r+r-rLIt..HIIVN FUH PERMIT - SAN JOAQUIN LOCAL HEALTH DIS"')ICT 1601 E. HAZELTON AVE., STOCKTOt.. E:Ai�1 Telephone 12091 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED Ut, (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump a NV"MEWk tom. This application is Local Health District. PT&PPIMME"s of the San Joaquin Job Address ! C 611V . �q� City ,_,L Lot Size PM Owner's Name ( Address IM0 Allow row 14 j S eL` .�,� Phone yds)6716– I Y f , i Contractor�5!1 Q2hn # Address F �,-z 3Z 3 IC�''1'� r �A- Litense NoCS'7-S Phone/` 6 -727 ' TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION-�d �' i PUMP INSTALLATION ❑ SYSTEM PEPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES S DISPOSAL FLD. PROP. LINE i3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial L1 Open Bottom ❑ Manteca Dia. of Well Excavation 1 Otr Dia. of Weil Casing i ❑ Domestic/Private 04 Gravel Pack 14 Tracy Type of Casing PYC i Specifications 1-1 Public CI Other F1 Delta Depth of Grout Seal Type�ofGrout I i Irrigation '22 Approx. Depth I I Eastern Surface Seal Installed by bet EvldVeti:�s,rrr p_ _ _ i Repair Work Done ❑ Type of Pump H.P. State Work Done Welt Destruction XL Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) *[Installation will serve: Residence— Commercial_ Other 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. TREIA PLT. Method of Disposal Distance to nearest: Well Foundation Property Line ��if/�LEACHING LINE Ll No. & Length of lines Total length/size !`r FILTER BED ❑ Distance to nearest: Well Foundation Property Line --rr SEEPAGE PITS I I Depth Size Number �vjlSUMPS Ll Distance to nearest: Well Foundation Property Line , DISPOSAL PONDS F3 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensre l tion laws of California." it The applicant must call for all required inspections. Complete drawing on reverse side. of Signed X Title: Gia Date: 20 Q . FOR DEPARTMENT USE ONLY ' Application Accepted by Date Area Inspection b l�j _'�`fel PB Date Y �__D' ° Final Inspection by Date / Pit or Grout Ins 16 �. Additional Comments: �' #i %.J_ G� irri- E. �Pi1 c -,�� c. tl,..�° [AJ ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk.,$CA 9521]1 } I FEE AMOUNT DUE AMOUNT REMITTED C INFO SH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.1/95) Ir� S, dQ EH 11.2e :?