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Art —1it1Vrlr r-Vry rr<ruvrr+ SAN JOAQUIN LOCAL HEALTH DIST CT j 1601 E. HAZEL T ON AVE,, STOCKTON, CA + Telephone (209) 466-6781 - ' PERMIT, EXPIRES Z YEAR FROM DATE ISSUED (Complete in Triplicate) j I-: •-- E.qi Application is hereby made to the San.Joaquin Local Health Distridt 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. r, Job AddressCity T.¢�,r Lot Size PM Owner's Name �Gu(firG.}✓y �ieP Address sd'o24 S7�N�i�j n t:� iCt�f� Phone �'�'6c�xS.¢�✓Ta.✓� Cf Contractor vf✓G 1411J1,'— Address 1,fSJ` G✓/ceoc i 4"�fr License Na. C11_� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER X,50lizz F$ sC((ZVCW ;CJS t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. Llff��E FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 112- ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-1 Public Cl Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by LL _ Repair Work bone 0 Type of Pump H.P. Well Destruction ❑ Well Diamer Sealing Material (top 50'1 e •„ Depth FT P=ilfer Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 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 PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 4i LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ 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 ❑ 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." 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, 1 shall employ persons subject to workman's compensa- tion laws of California The applica m t call for all ire i pections- om ete drawing on reverse slide Signed X Title: . � "v`7 G. . Date: FOR DEPARTMENT USE ONLY A Application Accepted by 1"1—�� Date L� re } Pit or Grout Inspection by _ Date Final Inspectr by at Additional Comments: ! l o� ❑ Stk 466-6781 ❑ odi 369-3&1 ❑ Manteca 823-7104 Tracy 835-6386- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BoK 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO C R +.EH 13-24(REV.1 i N 5) EH 14-29