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APPLICATION'FOR PERMIT IS301A83S/11WH3A k SAN JOAQUIN LOCAL HEALTH DISTRICT H11V3H `VIN3W02103 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)-466-6781, PERMIT EXPIRES 1 YEAR FROM DATE ISSUEItha (Complete in Triplicate) ;:VApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or installe(r(ei�nldescribed. 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 Local Health District. r 1_ 4 ' Job Address `�� `�` 0'„9'x+`,—_ City Zob j Lot Size PM mr'. (�a-40 + S. Cie lke� Zh 40161 Owner's Name Address ,zPhone [� 936 78 Contractus All Termlh E aa�r40 Alli Address 3_7SY 1 fd 117' $_-V"11eoC14 License No.4'3-?636 Phone �b�771-O,ZZ_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER KIV0,14/?hy We,// DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE UU FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Al ❑ Industrial ❑ Open Bottom 11 Manteca pia. of Well Excavation S// Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -STe-b, 40 PVC. Specifications C'ppyte�� Gr� f7 Public ❑ Other ❑ Delta Depth of Grout Seal *p'5_0 Type of Grout• Re /'?fY$ I I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by 41) rrld'h pnalmq/At,Ar— �or15u/7att�+ Repair Work Done 11.0 -=-7Type of Pump H.P. State Work Done _ Weil Destruction ❑ Well Diameter , 6? Sealing Material (top 501 nit+r +,lU�i, Depth -7 j Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I.I- DESTRUCTION I 1 iNo 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. Ll 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 i SEEPAGE PITS i I Depth Size _ Number SUMPS Ll Distance to nearest: 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." Contractors 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." Q F The applicant st call f 11 re wired inspections. C 'de. DlZt.w-dq 1 Ah6l e.G(� ' # Signed Title: cJ Date: -3a QEPARTMENT USE ONLY Application Accepted by4.�(� R Date f Area Pit or Grout Inspection by Date Y6- rY Final Inspection by _ }_ Data { _ Additional Comments: rjG v a4� c, e�o. -� G6 f o�.t 6,1- 7",J ❑ 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'IVO. i INFO t + EH 13-24(REV.1/H s) -FH 14-26 r.