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r11 I LI♦rM 11V1• 1 VII 1 L/\IY111 - _ - -- AN JOAQUIN LOCAL HEALTH DISTRICT \r� i�01 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67811 ` PERMIT p T EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) rtlF� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workE#1� i�1 `'�Vtpplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and gulations of the San Joaquin Local Health District. Pa,-k;ny Aot • /1` Job Address Nc` It!`e r12119,0— 3^ tz lebnn �' f OL 24 City Lot Size PM 1 47/yOwner's Name &14"10 �C�ot�r�tk jg� Address �� W. � ASfoGKlb/) Phone — 47 Contractor Addressu �' License No. Phone%/d TYPE OF WELL/PUMP: NE WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ L�a�l.•�0/,,�3 G✓{lg DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private *ravel Pack ❑ Tracy Type of CasingpIVGy�� 4jaWA/Specifications ❑ Public ❑ Other ElDelta Depth of Grout Seal )Ila f i Icy Type of Grout s4[� ❑ Irrigation L&IdApprox. Depth El Eastern Surface Seal Installed by CeM w�p Dp+ Repair Work Done ❑ Type of Pump S1l6 H.P. i State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 5011 X�OI11{'CI^;n Depth Filler Material (Below 501 h�,ln/Wif TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method 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 ❑ 1 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 applicant ypust call for all2 .,nspectorwired is. Complete drawing on reverse side. Signed ' Title: IV- Date: PregOR DEPARTMENT USt ONLY Application Ac ted by Date v Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE INFO AMOUNT DUE •AMOUNT REMITTED H RECEIVED BY DATE PERMIYNO. + EH 13-2 (REV.I i w sl �� / EH 1526 � O � I