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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone- (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address OO `4& Ci Lot Size PM Owner's Name r G!/f GK��Sa r Address 7r �S'©c c�`i Lvdh_ Phone 7 3 Contractor f64= PY_14 dVss "7 License No.r��?i Phone TYPE OF WELL/PUMP: NEW WELL Ji�- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION R1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONS ( AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom E] Manteca Dia. of Well Excavation 11 Dia. of Well Casing &5 " Domestic/Private Ld Gravel Pack ❑ Tracy Type of Casing ' r/G Ss"H/�GoSpecifications M Public ❑ Other ❑ Delta Depth of Grout Seal .22e^ Type of Grout 9 646S (� 1 1 Irrigation X�2APprox. Depth I 1 Eastern .. _ Surface Seal Installed by Repair Work Done ❑ Type of Pump rc<4 H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 .S'yfc"r cs 17 Depth MS'S Filler Material (Below 50') A?��/ u C TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION € I (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 ❑ 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 1 1 Depth Size Number SUMPS L] Distance to neatest: 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 subcontracting 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 applicants must call for all required inspections. Complete drawing on reverse side. Signed X ,, /./ Title: �/"1 L G r=tr Date: LZ_.— �R1)=AFITMENT USE ONLY Application Accepted by C f -___ _ Date 1 �l A l Area O 0 Pit or Grout Inspection by Date*RWiK_ Final Inspection by Date 1.1247yN Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO CASH I +.EH 120 tpEV.1 i n 51 �J r(?�( 'yr it 1-� I13i 1 EH td-4-28 f v l� 111'�