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., CA 9E201 Additional Comments: 11- SrIc 4E6-6781 • Li Lodi.; 369-3821, _ .....0.Menteca _1323 7104 _ Tracy 83§-638S _ , Applicant - Return 311 copies tot' Environmental Health Permit/Services 1'6)1 E. liezedon Ave., P.O. Box 2009, •••••.1 4 FEE iNFO EH :124 1REV. EN 14.28 RECEIVED BY L AMOUNT DUE AMOUNT REMITTED DATE' PERMIT' NO, 7- 'To-j7 Application is heieby 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 Sao Joaquin Ciiinty Ordinance No,.5•19 for sewage or No. 662 tor well/pump and the Rules and Regulations of the San Joaquin 7 LOC.81 Health District. ,- Liet-ilkiL•___._ Address NEW WELL Li WELL REPLACEMENT 1.1 DESTRUCTION i 'PUMP INSTALLATION C SYSTEM REPAIR L2. ' - OTHER C DISTANCE TO NEAREST: SEPTIC TANK ____ ____ SEWER LINES ___ .____ DISPOSAL FLD.__— PROP. LINE _- 1 FOUNDATION _ AGRICULTURE WELL _ OTHER PITS/SUMPS . , INTENDED USE TYPE OF WELL 0 Industrial i 1 Open Bottom i - 0 Domestic/ Private ‘„)„.;.• Li Gravel Pack Li public t ' I El Other I . _ Seating Material itop 50') _ a aria (Below 50') DEST TION I INo septic system permitted if available within 200 feet.) Installation :will serve: Distance to nearest: Well SEEPAGE P*)TS ;AV-Depth _ARS f. .__Sita _ ..3(da 1 -r-ii.•\-------• i ' _ Number _ _._! ___...!_____-- SUMPS I LI • Distance to nearessT--"'We'lb6--/-i" Foundann .1.\ 4 ' . Property 'Line Home owner or licensed agent's signature certifies the folitiwing:"i.'i,ertifY that in the performance of 'the work for which this permit ia.iSsued, 1 shall not - emplay.aniparson in such manner as to become subject to workmin's ctimpensation.lawsof California."Contractor' hiring of sub contracting -agnature certifies the fallowing: "I certify that in the pert oirnanCe of the work for wflich this permit is jssued, l shall employ persons subject to workman's COrnpensa. 'Signed non laws of California." • The applica Application Accepted by Pit or Grout Inspection by Date _ s for all ed i Con2pfetadrawin,g ori reverse side. _ Title: FOR DEPARTMENT USE ONLY _ Date Final Inspection by ••• Date:. `-%.• • -ra• , %1-1 APPLICATION FOR PERMiT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA:ZELTON AVE,, STOCKTON, CA Telephone (209) 466:6781 PERMIT EXPIRES '1 YEAR FROM DATE ISSUED (Complete in Tripiicate) City Lot Size 4 PM Job Addr Phone Owner's Name Contractor ____ TYPE OF WELL/PUMP: I • Irrigation Repair Work Done Well 'Destruction TYPE OF SEPTIC WORK t Number pfitiy rig u _ -Character al soil to a depth of 3 feet: — SEPTIC TANK Type/Mfg ___ PKG. TREATMENT PIT. 0 0 Type of Pump Well Diameter Death : NEW INSTALLATION Residence _V_ Comma Number of _.,_Approx. Depth Address PROBLEM AREA CI Manteca .1-1 Tracy SI-1 Delta •• CONSTRUCTION SPECIFIC Dia. of Well Excavation __.--_.___. Dia. of Well Casing Type of Casing _ Depth of Grout Seal Type of Grout I I Eastern Sur1ace Seal Installed by State Work Done ___-- Other re 2 ...' t .1, __ _Water fable depth _Sapacity_ -- _ No. Compartments , ___------..../. '-.... Method of Disposal '-foundation _......z•—)_._-!•1__:,Property,Line -•-• R 'Al .A zt) rk License Noad4,5_24/__Phone`.•_3.21-1 :Alike sewer LEACHING LINE Cy' No. b Length of lines __CI ) .. -..--- \ - ••• - 4 -.-„.•_..: FILTER BED LI Distace to nearest: Well Foundation 3A2 f"'", C-0 1 - le'rigth/size_ • DISPOSAL ?ONDS f -I rules and regulations of the San Joaquin Lot -al liealtli Di Strict. i I\'- t . I hereby certify that I have prepared this application and that the work will one in acciortarideWith:San Joaqui county ordinances, state laws, and j.