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�.;i� r�rr�i�.i-a t taw rvrti rcntvu r SAN JOAQUIN LOCAL HEALTH Dlbrs-tiICT s 1601 E. HAZEL%ON AVE., STOCKTON, CA ---- = Telephorhe 09)',466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Piplicate) Application is hereby made to the San Joaquin Local Health District for'apermit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No„18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address L[ kv G -,Vire`�' (?�{�� ' s.t,�*y.`{ 5' ,r City Lot Size.— �• Rr'�r Ptd Owner's Name.'• jr: !J 6+ J 1 : 7 Phone + j ? Address Contractor Address `r '. &4' License No,2 J % Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ `"OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALFLD. -20K PROP. LINE _ FOUNDATION: AGRICULTURE WELL OTHER WELL PITS/S' UMPS------------ V* INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 14 ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia. of:Well Excavation Dia.of Well Casing Domestic/Private )R Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other n Delta Depth'of Grout Seal T ., ype of Grout I J.Irrigation _Approx. De if} 11 Eastern' Suri cd.`Saai-lnstalled by Repair Work Done El - Type of Pump �� t�• H:P. State.Work Done' Well Destruction ❑ Well Diameter- Sealing Tti 4erial (top 50') —i �AL.✓: - Depth_ 2 yo Filler Material.(Below 50') s ° TYPE OF SEPTIC WORK: NEW INSTALLATION I,7 REPAIR/.ADDITION I I DESTRUCTION 1 1 (No 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: SEPTIC TANK Water table depth t' �] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well -• Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws rules and regulations of the San Joaquin Local Health Di?;trict. , and 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California.” The applicant must call for all required inspections. Complete drawing on reverse side. ff r. Signed X_l•;_t I`=.a� � ml Title: t-I Date: FOR DEPARTMENT USE ONLY Application Accepted by �a Date v Area Pit or Grout Inspection by Date Z 5;__ Final Inspection by--Zx MDat e Additional Comments: ❑ Stk ,466 6781, �O Lodi 369-3621 ❑ Manteca 823-7104 .. C3 Tracy 835-6385 Applicant- Return allcopiei to:,Environmental Health Pormit/Services 1601 E.tfazolton Ave., P.O. Box 2003,Stk., CA 95201 t f~ FEE AMOUNT DUE `- AMOUNT REMITTED CK s INFO CASH RECEIVED BY DATE PERMIT"NO. �.EH 13-24(REV,t/ 5l �} - 'EH 1428 • ;, --r''2S3S