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RECEIVED NOV 1 7 1586- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. Job Address 3S 6NEgortE9 + L19u� _ city LOOL Lot Size I 1',+ PM [.1 Owner's Name etup 1 i 1 t_ (0 w Address S�S k ST, ri Ort Phone 02 �d1<!J D9ra".. Lxao2�i>: FrrF,, owr G�? q iCi l 9soao�-� Contractor_&NEV E Srxr�,�f Address 3 0- n J &v License No. e�12GY Phon� / I:rl-! TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION Q h er.br�f we l j v y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES h DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS InRdustrial El Open Bottom ❑ Manteca Dia. of Well Excavation L9rr rt I i'l6N I Tp411y G 1NE[t Dia. of Well Casing � ID Domestic ovate 04 Gravel Pack ❑ Tracy Type of Casing- k a ihc.- Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 29-1 i ❑ Irrigation � Type of Grout { Approx. Depth ❑ Eastern Surface Seal installed by 4P.04,1P0 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Z�r Sealing Material (top 50') Depth d( Filler Material (Below 50') F SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewe available within 200 feet.) Installation will se Residence_ Commercial_ Other Number of living units: umber of bedrooms f. Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg er table depth PKG. TREATMENT PLT. L2Capacity No. Compartments Method of Disposal Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. & Length of lines 1101,11 ength/size - FILTER BED ❑ Distance to st: Well Foundation Pro Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation �. AL PONDS F-1PropertyLine 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 California." The applicant must call for all requir d inspections. Complete drawing on reverse side. Signed Title: ole Date: FO T NLY Application Accepted by Date 9— A Pit or Grout Inspecti Date Final Inspection b Date rte` "ZA��: �p Additional Comments: c _1 ❑ Stk 466-6781 ❑ Lodi 3621 ❑ anteca 104 ❑ Tracy 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 K INFO RECEIVED BY DATE PERMIT N0. + EH 13-24(REV.1/e 5) 3v.7 Ota {�.0,0 EH 14-28 i