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i1YYLkl,H+rUt� rUn r-Lnrvur �S` N JOAQUIN LOCAL HEALTH DISTRIC 0 Po p�► �� 1601 E. HAZEL.TON AVE., STOCKTON, CA ,�.,. Telephone (209) 466-6781 y�� - , z PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0XV, i (Complete in Triplicate) Applit Oi iis.¢i)B 0if,;rfaae�e to the San Joaquin Local Health District for a permit to construct and/or install the work herein'dbscrits Ais application.is�US mai7�`rccn,,; i1t51iaie l with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wall/pump and the Rules and Regulations of the,SO-,J-63q]i ) Local Health District. Job Address ZS -TrAtq r)10 A� City rac Lot Size PM R zcxf>.41eJ�c[�� P" i..1.-1 4s Owner's Name AM4 t'r J" Address Snh c -� qq!4 Phos 1-710 V&b L--. ContractorXJ Y Addvess 1 q564 f License No 6 Phone(416)–M TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, ,PROP. LINE GC*•1brf�f [�rY (14.1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATtOtiS I f ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 Dia. of Well Casing 0 Domestic/Private Grave! Pack Tracy Type of Casing L Specifications I'i Public n Other 171 Delta Depth of Grout Seal NI Type of Grout + 1 L+f I I Irrigation —..Approx. Depth I I Eastern Surface Seal installed by I Repair Work Done ❑ Type of Pump Al. H.P- `_ k'lt _Sta�te Work Dong � Sealing Material (top 50'1 [i , Well Destruction ❑ Well Diameter r i S y � Depth 3C)RFiller Material (Below 501 TYPE OF SEPTIC WORK: W INSTALLATION I I REPAIRIADOITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is S available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of ours Character of soil to a depth of 3 feet: ater table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foun Property Line LEACHING LINE ❑ No. & Length of lines �Iength/size, FILTER BED D Distance to nearest: I Foundationne SEEPAGE PITS I 1 Depth Size _ Number SUMPS Ll anc�tonear�est,: 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,I shall employ persons subject to workman's compensa- tion laws of Califo The applicant 1060 dins tions–Complete drawing on reverse side. SAN JOAQUIN LOCAL HFAI=TH DISTRICT VIROf�MENTA.L (-IEA TH.DIVII]SION r7 / 1/ t. Signed Title: DBtekVf'-�y4 I FOR DEPARTMENT USE ONLY. Application Accepted by Date l--I/% Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D 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 s FEE INFO AMOUNT DUE AMOUNT REMITTED CK R RECEIVED BY DATE PERMIT'NO. + EK 13.24(REV.i i RW EH 14-28 �0 illirL / `r