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SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone [2091 466-6781 PERMIT EXPIRES I'YEAR FROM DATE ISSUED, • .,. .,.., .�..-. . .,. .;. ,, . . _ ,. �. . ,� -(Complete in.Triplicate) -0. - Application is hereby made to the-Sari Joaquin Local Health District for a permit to constrtict and/or install the work herein described. This application is made in coinpliance 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. APN.fly3-lao-/;. i Job Address Cit tot Size 1/4 CM: PM Owner's Name � �dlGs Address Phone��G> &yz -_ Contractor ' '.Address _ ? „- License Nn.2n-f h. Phone , TYPE OF WELLIPUMP: NEW WELT WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM REPAIR 171 OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANKCl SEWER LINES _._ DISPOSAL FLD.._ _ PROP. LINE''"> FOUNDATION�� AGRICULTURE WELL _ _ OTHER WELI�i± PITS/SUMPsjr� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing I Domestic/Private L:] Gravel Pack ❑ Tracy Type of Casing I Specifications i Public Cl Other 171 Delta Depth of Grout Seat _ Type of Grout.L_'�...-,i t I Irrigation _Approx. Depth ! eastern S,uface Seal Installed by C:." Repair Work Dore L3 Type of Pump H.P. _,. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIRIADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Re 'dance l Commercial ___ Other kA Number of living units: Number of bedrooms ✓ LS/( 6 Y <" Character of soil to a depth of 3 feet: ) Water table depth SEPTIC TANK ❑ Type/Mfg G Capacit� _ ' /1No. Compartments _ l PKG. TREATMENT PLT. ❑ tf Method of Disposal � ' Distance to nearest: Well f L Foundation.s.Rl— Property Line LEACHING LINE No. & Length of lines �j--�+a e+e� �cs.-_- i-otal length/size r"Q FILTER R BED f_ Distance to nearest: well / _ � Foundation�Q _ Property Line SEEPAGE PITS Depth _2s Size _ _._lLr� �� t Number_.-S _ SUMPS L-I Distance to nearest: Wel4*.�4_ Foundation��_� Property Line DISPOSAL PONDS Ll 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 fw 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: "I certify that in the performance of the work for which this permit is issued,1's0all employ,persons subject to workman's compensa- tion laws of California." The appli/cantt st- If for II re +red inspections. Complete drawing on reverse side. Signed X_ _�� Pte.•142L e Title: } Date' FOR DEPARTMENT USE ONLY Application Accepted by Area s or Grout Inspection b4 Data Final Inspection to Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmenfal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY o DATE PERMIT'NO. EH 14"26 + EH 7321(REV.i/w s� Q v► /�/g �