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4 :� HYNLiI.N i iUiV run Ncnwtr► p } SAN JOAQUIN LOCAL HEALTH DISTRICT ' „9 1601 E. HAZEL T ON AVE., STOCKTON, CA~ L ��A �C� � Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSU (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w � n described.This applicatwn is made in compliance with San Joaquin County Ordinance No.549 for sewage Or No. 1862 for well/pump and the flule �arg� ulatiorls of the San Joaquin Local Health District. . �D D G }} Tr," Lot Size PM Job Address 1^Gt,V1�1 I�I'1 R aaL• City L70`t `7 (oq • Phone ` Owner's Name � Address ��5� � ✓f 8451 a v sc+' D$-Zz3o-fo z� Contractor �Gr� On Address � 7.T �CUf' License No. Phone TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑ Si '6r r" PUMP INSTALLATION El ! SYSTEM REPAIR ❑ OTHER �P r Y RS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD.>J-7> PROP. LINE I FOUNDATION AGRICULTURE WELL >49 OTHER WELL PITS/SUMPS Zt� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS NIA ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing ❑ Domestic/Private ❑ Gravel Pack ' Tracy Type of Casing "Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Re air Work Done EJH.P_ State Work Dorte Type of Pump & Zestruction ❑ Well Diameter Sealing Material (top 50') aptoru.'f1Cn. Depth — / Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR'/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is v available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 17Method 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 n J un rdinances, 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 pert or ce of a is tis permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of liforn -C t tor's hir or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is iss o rsons s bject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: if 6F Date: FOR DEPARTMENT USE ONLY Application Accepted by Date—9_ Area Pit or Grout Inspection by Date' Final Inspection by ` Date it Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant ca 847104 ❑ Tracy 1135-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009. Ptk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT''NO. INFOat xL007-1 4 + EH 13-24(REV.1/e 5) ! � � 1 �� EH 1478 - n" f • _�.—.__�__.�.-.._..-..,..........,._ ...�.-..._ __c_a_.irr*;•... ._.:G.....-, 'w'.":6'�e;S:-•--j;r�.:�: �-...._�s�.�r�,i�.a.'..,it..b� �V.:a_a.ia..._�a .