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e APPLICATION FOR PERMIT U, � . _. . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA APR ('j j 1 Telephone (209) 466-6781 " ` P9g -+.�Y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRO ENTAL HEALTH {Complete in Triplicate} PERMIT/SERVICES 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 !3 'rr c City 2 Lot Size aO VS-3 rtyf Owner's Name K40 04, cof- ?-, Address f?6• S. /q6 Go i Cil Phone CatSR -2 7.3 Contractor i)a+, �xylordf�y Address C4 License No. �62 Phone `lis 930-&ySQ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1`gQn��vrigS 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 J� i �V 4 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8°' Dia. of Well Casing • $ Domestic/Private f�,Gravel Pack Q Tracy Type of CasingPi/G Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �' T Ca.�enj bz,k�fl� irrigation V` Type of Grout ❑ Irti 9 ,?_Approx. Depth ❑ Eastern Surface Seal Installed by 6r6�A„d.,. tee- Tec4.,al6 Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') (\[ ` Depth I P Filter Material jgelow 601 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 i 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 i. Distance to nearest: Well Foundation Property Line LEACHING LINE Q No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f 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 k 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 " Y 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 required inspections. Complete drawing on reverse side. Signed X� - Title: 13 t!,ra,n ,✓�{zr /ccA Date: . 3I�8 7 lPT D E ONLY Application Accepted by Date Area j Pit or Grout Inspe o y DaI�`_(D Final Inspection by D t / C 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 RECEIVED By DATE PERMIT"NO. H I. ♦ EH 14-24IREV:-.lin5i dole) 3 S ♦ �Q �—�3 „-� �� g7 ti1.13 EH 1 .29