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0 LOCAL HEALTH DISTRICT is P Al tAe�" SAN JOAQUIN 1601 E. HAZEL`jON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JCornplete in Triplicote) Application is her eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dW"S"iW-4if?.Y.Ml n , made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulation of the San Joaquin Local Health District. Job Address A00 -T-hdus-h-;41 Pok A-, city t1411il-eA— Lot Size-114A—C.'es PM-- Owner's Name 91,*6Tjj1;C-3 Address W rMIk5fV&1 RI"k ILI is"2—al EVOm Rd, Contractor, Address Lilco,P;H51wrq. Ck igg License No.fLOTO 11fi" 61V10tZ*n — - --&� Z TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT El DESTRUCTION 0 X ((,) PUMP INSTALLATION 0 SYSTEM R�PAIR 0 OTHER DISTANCE TO NEAREST: SEPTIC TANK V4 SEWER LINES >5'0 DISPOSAL FLO. P& PROP. LINE,� FOUNDATION AGRICULTURE WELL A* OTHER WELL,>�� PITS/SUMPS A* INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing -2 C1 Industrial 0 Open 4onorn Dia. of Well Exc vati T '16 `= 1%2:p /.I-�� ,LAA I] Domestic/Private -@ TPack L] Tracy Type of Casing Ir I ri� W Specifications �,.Pblic I n Other F1 Delta Depth of Grout Seal' 0 out&1*446 �tj top,V19 4P J ion Approx. Depth I I Eastern Surface Seal Installed Repair Work Done 0 Type of Pump H.P. State Work Dom. Well Destruction 171 Well Diameter Sealing Material (top 501 Depth Fillet Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) is Installation will serve: Residence Commerl— Other Number of living units: — N I s Character of soil to a depth of 3 feul: Ir I A Water table depth SEPTIC TANK 0 Typ,/Mf� pacify No. Compartments PKG. TREATMENT PLT. 111 6 Method of D: isporsal Distance to nearest. 9.11 ion— Property Line LEACHING LINE El No. & LIqpth of lines L Total length/size FILTER BED El Distanc t-N4��real: / Well Foundation— Property Lim SEEPAGE PITS I I Depth t7t-- Number SUMPS Ll Distance to nea 4Vell I lFoundtion— Property Lim DISPOSAL PONDS El 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 Diltrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perrnit 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, I shall employ persons subject to workman's compensa tion laws of California." The applicant at call for all req d inspections. Complete drawing on reverse side.—C,�,e Signed Title: Prai&ct-,FA,-,i a- V 041flill.A FOR DEPARTMENT USE 00' &K ENO Applicationf,'apte:by i (fl/I .L---� Da Area lot—v,j py' [I — Nnearftt gell--�&Fotunat Pit or Grout Inspection by — Date— Final Inspection by Additional Comments: 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Senricas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ---F— FEE �UNT DUE AMOUN :HH 13-241(REV.i,n 51 INFO T REMITTED RECEIVED BY DATE PERMI�. 4-25