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IV JUHLLUIIY LUI.HL f1CHL1A UlJlftlV,r'-.'� 301 E . HAZELTON AVE. , STOCKTON, CN Telephone (209) 466-6781 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 made in compliance 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. , rruL �� {��, � 1, n , 1 C, T/�� (]� X 13r-z3o-ol Job Address 404 7�h..zM OW � J�r - city ,J.IS[i.[�L1L� Lot Size PM CA?tRLa � s G YA!7fA L C{2�A M � /VIA KI 114 � D PiffTE2 C-0 Address 3 / I ET Pimne Owner's Name jU I-T-6Br ,�ACnO '910 Contractor A-MCON Address1+50 flidnBnR 2Y/m License NoAt MG 02 Phone -3 . � - � TYPE hone3� TYPE OF WELL/ PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER f�A_ /M001-Tv ZI N6 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 21� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation' / Dia. of Well Casing ❑ Domestic/ Private ❑� �Gravel Pack ❑ Tracy Type of Casing p V ��/ Specifications ❑ Public Pd�' O/�M�Pr �ND ❑ Delta Depth of Grout Seal '� J;/ Type of Grout ❑ Irrigation +QL pprox. Depth ❑ Eastern Surface Seal Installed by PL _ S i �� //��--rr,,��.�r,14� Repair Work Done ❑ Type of Pump �T/( (A.� IU`(H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top SO') MON 11bR1 Nq Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR /ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewer is available within 200 feet. ) Installation wilt serve: Residence _ Commercial _ Other , Number of living units: Number of bedrooms Character of soil to a depthof3 feet: Water table depth SEPTIC TANK ❑ Type/ Mfg Capacity. No. Compartments PKG, TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting 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 fora J,tegwr innssp�ections. Complete drawing on reverse side. Signed X� l r - Title: OWNER Date: 10 - 22 - 86 9 f9'DE RT SE ONLY Application Accepted Pit or Grout Inspe io yr. Date Final Inspection by r� / r Date 11L4K' Additional Comments: ❑ Stk 466-6781 ❑ 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 FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT' NO. INFO CASH EH 1124 (REV. „ x et EH 14-M 35-!TD//vJ. �GPiJrr.�i? Ld20G,0�1Et //v� . oOr�Jtay�eC4A ;7