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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.)$FJgr well/pump and the Rules and Regulations of the San Joaquin Local Health District.} Job Address r ' S i\� . C-�L--- B�` - City f J I Lot Size 4 PM Owner's Name QF(-) &-V tt Kf A 1-1 A-S-- Address 4 ^ C 4C, �OeV& Phone �3 ^ Contractor E ^ Address S.4 V/ -� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU TION 171PUMP INSTALLATION ❑ SYSTEM REPAIR L1OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANSEWER LINES OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM ARE ON5TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications j VI Public I-) Other l l Della Depth of Grout Seal Type of Grout ! I Irrigation rox. Depth l 1 Eastern rface Seal Installed by _ Repair Work Done Ll Typ f Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (NP 501) Depth Filler Material (Beiow 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION1v1` REPAIR/ADDITION t 1 DESTRUCTION l ! (No septic system permitted if public sewer is /• available within 200 feet.) Installation will serve: Residence L Commercial_ Other / Number of living units: Number of bedrooms 7- rf ,rt Character of soil to a depth of 3 feet: l��1'L Water table depth J U I SEPTIC TANK / Type/Mfg L / Capacity ��Q _ No. Compartments PKG. TREATMENT PLT. ❑ j l Method of Disposal Distance to nearest: Well &6 Foundation�� Property Line LEACHING LINE ❑ No- & Length of lines to Total length/size FILTER BED ❑ Distance to nearest: Well . Foundation Property Line—- SEEPAGE PITS I'l—Depth Size 3(� a Number SUMPS '' Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS: ❑ I 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 G employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 0 certifies the following: "I certify thai in the performance of the work for which this permit is issued, k shall employ persons subject to workman's compensa- tion laws of California." rn The applicant must call for all required in ctions. Complete drawing on reverse side. ^ Signed X Title: _,CA A Date: FOR R DEPARTMENT USE ONLY Application Accepted by ZgeYDate r (' Areaol Pit or Grout Inspection by Date Final Inspection by L2 Datea Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2609, Stk., CA 95201 FEE INFO AMOUNT jDUE � AMOUNT REMITTED CASH CK i RECEIVED BY DATE PERMIT NO. +.EH 13-21(REV.1/n 5) � O. `w � EH 14-26 �� 9 --r