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API-r _ 5N FO ` : . R PERMIT SAN"JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 �a � 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 1 made incompliance 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. .. .. Job Address ^J�IFWFI�&f- aVr . l� `71 W City .rl� E`y�Lot PM x Owner's Name Address !l-1 r�- _' I��I�� _.G� '. _. Phone Contractor 'J �1'i.13 Address iwd License No. Z��6Phone 94"77-45 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ k#ER"�_ [� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' D F31AL LD.. PROP. LINE FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS C INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS i ❑ industrial ❑ Open Bottom ❑ ca w °Dia. of Well Excavation Dia. of Well Casing r f ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications ❑ Public ❑ Ot [U] Delta"" Depth of Grout Seal Type of Grout El Irrigation �pprox. Depth ❑ Eastern-,- Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ( Well Destruction ❑ Well Diameter"""`^` w Sealing Material (top.50') i Depth Filler Material l8elow 501 --.-TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is.. vailable within 200 feet.) Installation will serve: Residence 4 Commercial____ Other Number of living units: Number of bedrooms T Character of soil to a epth of 3 feet: Ap Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal I: 0,W FDistance to nearest: Well Foundation Property Line a LEACHING LINE Q-` No. & Length of lines Total length/size FILTER BED ❑ Distance to.nsarest: Well -- FoundationProperty Line SEEPAGE PITS ❑ Depth ` Size Number A SUMPS ❑ Distance to nearest: - Y Well Foundation Property Line DISPOSAL PONDS ❑ 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 Y 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all squired inspections. Complete drawing on reMrse de.ff�� Signed X Title: r✓�� Date: y FOR DEPARTMENT USE ONLY r Application Accepted by Date e L Area Pit or Grout Inspection Date Final Inspection by Date 'o —C l Additional Comments: e a' m ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ kjlhtecai 823-7104 EJ Tracy 835-6385 �.67 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. r + EH 13-24-[REV.tiwel "7 ?7-A1,742 � EH 14-28