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AP j T 5 SAN JOAQUIN LOCAL HE LTH D STRICT 1601 E. HAZE T ON AVE., S OCKTON, CA Telephone 1209? -67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iComplete in Tripli ate) 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. %62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address -3i1 �✓�1SiS�/ �� -– City— SkQ Lot Size PM Owner's Name Address je 0 Q Phone � r� � ssst:s Contractor /1 VA GY1rILOiTiATIb/t1 Address License No.�8afilas Phone � TYPE OF WELL/PUMP: NEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK NIA __ SEWER LINES DISPOSAL FLD.X&q PROP. LINE FOUNDATION –A60AGRICULTURE WELL OTHER WELL uZf PITS/SUMPS J(� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �n CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation SoDia. of Well Casing D Domestic/Private X Gravel Pack ❑ Tracy Type of Casi g NC4 Specifications f'I Public 114v1Xm%V1_ Cl Other F1 Delta Depth of Gr ut Seal • Type of Grout A/2w I I Irrigation WJ%iJ f�`Approx. Depth I I Eastern Surface Sea Installed by_211 ~ Repair Work Done ❑ Type of Pump AM H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {below ) F SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION t I DESTRUCTION i I !No septic system permitted if public sewer ' available within 200 feet.) Installation will Residence___. Commercial— Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: r table depth SEPTIC TANK ❑ Type/Mfg capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. & Length of lines length/size FILTER BED ❑ Distance to t: Well Foundat' n Pro Line SEEPAGE PITS Depth Size Number SUMPS LI Distance to nearest: Well Fou ndati 3n Property Line D AL PONDS ❑ I hereby certify that I have prepared this application and that the work will be don 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 pef son 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 California." The applicant must call for all required in ctions. Complete drawing on reverse side. j�rjp d jgT� I Signed X / Title: Date: 7AA FOR DEPARTMENT USE ONLY Q� Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental health Permit/Services 1601 E. H zelton Ave., P.O. Box 2009, Stk., CA 95201 aril_-.4 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO y/7 . EH 13-24 tREV.i i e sl /-� EH N-I6 �—