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A4P�LtrAT10 SAN�AQUIN LOGr{L HEALTH DISTRICT PERMIT NO. 1601 E. HRZELTON AVE., STOCKTON, CA Y DATE ISSUED Telephone (209) 466-6781 .4 PERM17 EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) J 10- emit to construct and/or install the work herein r. .. 549 for sewage or No. 1862 for well/pump Application is`hereblimadeotoish �enin°�dmQliancquin e withlth SanDJoaquin CountypOrdinance No. descistrict ribed. This application I Y o d,the Rules and Regulations of;lhe;San Joaquin Local N al baivision Name �� phone t QJob,Address Address 1 Phone i. 3 D& owner's Name License No. Contractor's Name �VJOt�� REPLACEMENT ❑� DESSRUCTIDN TYPE OF WELL/PUMP WORK: NEW WELL ❑ OTHER ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ PROP. LINE r � SEWER LINES DISPOSAL - PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK OTHER WELLL ��..— � FOUNDATION AGRICULTURE WELL 4 TY.PE OF.WELL PROBLEM AREA CONSTRUCTI�JN SPECIFICATION5 INTENDED USE —� Dia. of Well Excavation Open Bottom ❑Manteca r Industrial U ❑Tracy y � of Well Casing Domestic/Private ❑Gravel Pack ; Delta Type of Casing ❑Public ❑Other Approx. ❑ Eastern Specifications .Irrigation Depth Depth of Grout Seal Cathodic Protection Type of Grout Geophysical Surface Seal Installed by ❑Other State Work Done •"� ,�*' Type of ump �� H.P. Repair Work Done [� yP P (j Sealing Material (top 50') Well Diameter _ � t 1 ! Well Destruction - Filler Material (Below 50') Depths � No septic tank or seepage pit permitted if public sewer is NEW INS REPAIR/ADDITION ❑ ( available within 200 feet.) I TYPE OF SEPTIC WORK: Other Commercial f Installation will serve: Reside Lot size - f Number of living units: Number of bedrooms Water table depth I Character of soil to a d pth of 3 feet: No. Compartments Capacity SG I SEPTIC TANK ❑ Type/Mfg Method of Disposal E Capacity ❑ Type/Mfg Property Line PKC. TREATMENT PLT. �,_.�— �•. 1 Foundation SEWAGE SYSTEM �— Distance to nearest: Well �.� f 4 DESTRUCTION Total length/size E LEACHING LINE No; & Length of lines Foundation Property Line U � FILTER BED ❑ Distance to nearest: Well Size Number SEEPAGE PITS Depth Property Line .. ( ❑ to nearest: Well Foundation --SUMPS Distance DISPOSAL PONDS ❑ ,I. ' application and that the work will be done in accordance with San Joaquin county f I hereby certify that I have prepared this ati "I certify that in the performance of the work for which this ordinances, state laws, andirules and regulations of the San Joaquin Local Health in the ensation laws of California." Home owner or licensed agent's signatory PersonSen suchs the fmannerollowinas to becomeis,ubjectyto worinanh c mpensmance of the work for which permit is issued, 1 shall not employ n tune certifies the following: b LSz+M (C, Contractor's hiring or sub.contracting sig a �Cc Cam P � this permit is issued, I shall employ persons subject to workman's compensation laws of California. Date: l cant must call fors all required inspections. Complete drawing on reverse side. The app �USlE Signed X ARTMLONLY ❑ Stk 466-6781 Area .-- P Application Accepted by Lodi 369-3621 ❑ Manteca 823-7104 F Additional Comments: Date �� L} Tracy 835-6385 Pit or Grout lnspecfion by Date 201 Final Inspection by P.D. Box 2OD9, 5t k., CA 95 Applicant - Return all copies to: . Environmental ealth Permit/Services 1661 E. Hazelton Ave., PERMIT NO. 6 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE INFO } p 1'a Sc i) . n 4 IO/82 500 1 'EH 13-24 REV. 10/82 14-26 `�