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PUBLIC HEALTH-SERVICES --� — ' SAH JOAQUIN COUNTY t P. O. Box 2009 (1601 East Hazelton Avenue) r Stockton, California 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE. (Complete in Triplicate) Application is hereby made to the San Joavuin Local Wealth District for a permit to construct andlor install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1062 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. � ®Q O( a�r.� (sur k �-4 k Job Address City Lot Size Owner's Name -5 D 1 co._ 100 owe tI 3 f Address _� _».. amu' A Phone Contractor W 1 •1 61 Address 3033 r'heJLicense Mose SS —17 none �6—& °-7276 TYPE OF WELLIPUMP! NE ELL P& WELL REPLACEMENT v DESTRUCTION LI PUMP INSTALLATION 177 SYSTEM REPAIR C3 OTHER a 5oA LS,orL'nJ a DISTANCE TO NEAREST: SEPTIC TANK ^ SEWER LINES DISPOSAL PLO, PROP. LINE — FOUNDATION AGRICULTURE WELL _ OTHER WELL__ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !1 t © Industrial ClOpen Bottom (.1 Manteca Dia. of Well e;tavatian Dia. of Well Casing T i7l Domestic/Private 0 Gravel Pack VC i 1-1 Tracy Type of Casing Specifications I-I Public iii Other�t7+trtsr+h f 1 Delta Dopth of Grow Seal ZrY �,SL46,4'-e Type of Grout & �grov . I I Iteloation �,Approx, Dept I I Eastern Surface Seal Instailtld by _ Repair Work Done L] Type of Pump H.P. ._. ,.- State Work Done C4d^ Well Destruction O Well Diameter ,- 4 Sealing Material (top 50.) __. ___ Z S.1 D eQGi, Depth TM Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I I IMPAIR,'ADDITION i I DESTRUCTION [ I (No septic system permitted if public sower is available within 200 feet.( Installation will serve: Residence Commercial__- Otlrer Number of living units; Numbor of bedrooryls Character of sail to a depth of 3 feet: Water table depth_ SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG, TREATMENT PLT.GI Method of Disposal Distance to nearest: Well _ Foundation. Property Llne LEACHING LINE Cl No. 8 Length of tines Y- Total length/size FILTER BED U Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth _. Sire --.-r_��.. Number SUMPS L1 Distance to nearest: Well^. . Foundation property Line DISPOSAL. PONDS I-) I hereby cartity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinancos. state laws, and C rules and regulations of the San Joeouin Local Health Di}trirt, Home owner or licensed agent's signature certifies the fallowing: "1 certify that in the performance of the work for which this permit is issued, I $hail not employ any person in such manner as to become subject to workman's Compensation laws of California." Contractors hiring or sub-Contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's aompansa• tion laws of California." The e applicant must call for pll rBRui d inspections. Complete drawing on reverse side. / q ity� 'Signed X ��— 'Wt Title: Date: �( 3�� { U" .FOR DEPARTMENT USE ONLY Application Accepted by _. Date Are Pit or Grout Inspection by Drto— Final Inspection Date Additional Comments: © Stk 4813.6781 0 Lodi 369-3621 0 Manteca OM-7104 © Tracy MS-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMtITEQ K RECEIVED 13V DA71 PERMiT'MO. fNFQ . Elf 74-2•IREV,if A-,; 7 EM f�•2e p--�