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% e _ ro, ',>M`.,i'ts - y.,x 4,, ,�,, •Y!J r-1• w �'S LIl. gdr� rn-�"h^ r e .`.?� a �'4 .,i'1' Y.. _ -.: . r .zi�.�i 1601 E. HAZEL T ON AVE., STOCKTON, CA :4x I s � f � �i Telephone (209) 466-5781 PERMIT EXPIRES TYEAR FROM DATE ISSUED [,; (Complete in Triplicate) Fu ` I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d s r{b,E g. iigllation is made in compliance with San Joaquin County Otdinance No.549 for sewage or No. 1862 for welllpump and the work herein �, eSan Joaquin Local Health District. -7 Job Address 1 Z City Lot Size PM or y n j Owner's Name � !15 Address cam/� / Phone � �r� Contractor l /��S Address G:, � -.'License No. Phone TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ;R;Ii apMZ..rz:(,-SYSTEM R AIR )a OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. DepthIS�I� Eastern Surface Seal Installed by s� - Repair Work Done ❑ Type of Pump —�L� H.P. State Work Done,�,, lZ r i Well Destruction ElWell Diameter Sealing Material (top 501 _ .� �_ ✓�1. P e,0 }' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence— Commercial____ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well Foundation Property Line II LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line FSEEPAGE PITS I I Depth Size Number 4 SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 l F.- rules and regulations of the San Joaquin Local Health Di%trict. .4 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 —a1. equfrp . ns. Complete drawing on raver side. Signed X �i Title: pate: DEPART ENT USE O Y - 0. ' rl Application Accepted by �� Date _ Area" Pit or Grout inspection by Date Final Inspection byDate I Additions[ Comments: C"' ,v Y �'° do'.+ ❑ Stk 466-6781 C] Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t IEEE AMOUNT DUE AMOUNT f REMITTED CASH CK RECEIVED BY DATE PE[nRRMIT'NO. ' hn F�EH 13-24 1REVA I N 51 EH 14-29