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9 30- t.D ' 3 it-S4 bNzwv { ,AN JOAQUIN LULAL tttta I I1 1601 E. HAZE i ON AVE, S OCKTON, CA Telephone (209) 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Apphra;ior euin Local Health District for a permit to c nstruct and/or install the work herein described.This application is Joaquin County Ord made in coinpliarrce with San Joaquin No.549 for sewage or No. 1 for well/pump and the Rules and Regulations at the San Joaquin is hereby made to the San Joaq Local Health'Di5 riot: City <c1��c�c�y.� Lot Size PM Job Address !` �, � i.,s�� LI Cy �, e. � Phone -Z l 1 �. Address �W-aZzz Owner's Name �L L T.E�.t�=•v one License No.��-- Contractor I I Address DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WEL WELL REPLACE ENT ❑ 3 PUMP IRSTALLATION 17 SYSTEM REPAIR ❑ OTHER DISPOSAL FLO. PROP. LINE SEWER LINES PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK _�—— AGRICULTURE WELL OTHER WELL FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC ION SPECIFICATIONS ❑ Open- Manteca Dia. of Well Excava[ion t7 t Dia. of Well Casing 7� - ❑ Industrial Specifications k(Domestic/Private �Rravel Prack ❑ Tracy Type of Cas ng I R Datta Depth of Gr weal 3� 5 Type of Grout f'1 Public n Other - Approx. Depth l...I Eastern Surlace-Sea! Installed by ! I Irrigation i �_ State Work Done f'Pump H.P. Repair Work Done L] Type . Well.Destruction ❑ Well Diameter Sealing Material (top 1 Dept Filler Material.iBeldw '1 i TYPE OF SEPTIC WO K: NEW INSTAL`LION I i R[-PAIRI'i STRUCTION I I av A ailablerwthin 200 feett'ed if public sewer is Commercial Other " installation will serve: Residence Number of living units: Number of bedrooms Water table depth- a Character of soil to a depth of,3 feet: No",Compartments C7 Type/Mfg Ca a , ;. SEPTIC TANK Method at Disposal - T. ❑' TREATMENT PL -.� - '�' PKG. TREAT � Property Ltne Well A Foundat an P Distance to nearest: - " i ' p ngth/size LEACHING LINE L1 No. & Length of lines Foundation Property Line FILTER BED O Distance to nearest: Well Size Numbei SEEPAGE PITS 11 Depth MLn Property Line SUMPS L1 Distance to nearest: Well NV� 1E 0 . _ DISPOSAL PONDS ❑ �CNLj f� I hereby certify that I have prepared this appllcation and that the work will be d ne in dance 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: "l certify that i the performance of the work for which this permit is issued, I shall not ring signature employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's Pef�nsrsubj subject t workman�sgcompensa- certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ p tion laws of California." The applicant must call for all required inspections- Complete drawing on raver side. `� • Title: OF Date: Signed X l^(FOR D`EPARTMEN USE ONLY / Date $ t{Igs_ Area Application Accepted by '-- Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: 11 Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 al! ies to: Environmental Health Permit/Services 1601 E. He Iton Ave., P.O. Box 2009, Stk., CA 95201 Applicant 781 cop RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO �/� ..EH 13-24 1 REV.1/1`151 3 s ♦ da Q Ak�Q EH 1426 17 .Y