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or 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) I 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 Local Health District. Job Address flS' L°07719Lf /IUf 3'YO' N/D YOM l'7/Tf IlllZity PNAIM'19 Lot Size PM Owner's Name P/If/FII A/I3 e ElfCTA/C LUAddress P.U. BOX 930 S'TG XTON 9 XI Phone 9y2 39 Contractor GfNfiPAL C49NS7/PUCLAddress 11DSZ Z AVY 120 License No. Phone-81-2 TYPE OF WELL/PUMP: . NEW WELL IR WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Rye, Specifications f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ___ 8 7.4 _ Type of Grout ❑� �n7I ri tion WELL �4pprox. Depth El � Eastern Surface Seal Installed by PROZZY 125 Z2EeTR1i �+f ( 0 g[�13� Repair Work Done ❑ Type of Pump __NR H.P. IM State Work Dane_ Well Destruction ❑ Well Diameter /O Sealing Material atop 501 _Z14MORZ77f Depth Agog Filler Material (Below 501 COKE ,t3?ZFZZ .1 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION.❑ DESTRUCTION ❑ lNo septic system permitted if public sewer is available within 200 feet.) j 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 I SEPTIC TANK ❑ T ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ NrA 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 ❑ 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." The applicant must call for all required inspections. Complete drawing on reverse side. -/I-.86 Signed X JOh'N 11,011,3flN itle: E1VZ 4_rR- ZS'T//WWR Date: FOR DEPARTMENT USE ONLY Application Accepted by r Date / Area Pit or Grout Inspection by r ate Final Inspection by ►" Date IX Additional Comments: Of ❑ Stk 466-6781 ❑ Lodi. 369-3621anteca 823-7104 L163 Tracy 835- 85 ij Applicant- Return ail copies to: Environmental Aealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO 49 FEE A�MMOO)UNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NlO. � EH13-24(REV.1/851 /� .�� j EH 1428 / I .�