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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZE' �.I ON.AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRQfV;E.�N 7aL HEALTH (Complete in Triplicate) FERMIVSERVICES 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 f4SA+4gW At( bJItDB2 OCA111 s1 ihi16TifF OF&Tes�'R ulations of the San J Local Health District. e9 Joaquin � � - ENVIRONMENTALHEALTHDIVISION ` Job Address __ 4. c,i- k� S9Y�e.�'F SPE ePERMITcit N Lot Size f PM t Owner's Name r t C� pro e fes �ytif_,Address`ZS 59:t C-0 h �he+� Phonek� �33 " ['. 1780 1J♦PrrnDrn s-I-: c.�t',.F�.3 C j� Contractor � 6kc� lQ*�c�lcOh Address" vVl"�e [@, ��p�g License No.2- ph&")79733 TYPE OF WELL/PUMP: 3 NEW WELiSX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X /5Or! (jQrtho% DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -----!—'DISPOSAL 'DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL —PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { L1Industrial 11Open Bottom ! ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Iq Gravel Pack .Tracy Type of Casing t— S ❑ Public Specifications ❑ Other ❑ Delta Depth of Grout Seal /— ❑ Irrigation —A Type of Grout C�+'1 � --Approx. Dept stern Surface Seal Installed by Repair Work Done W❑ Type of Pump H.P. State Work Done ff n i t Well Destruction ❑ Well Diameter j� 14 , �� , Sealing Material {fop 50'} �p_n�r^In ►At0�-tq,1 I Depth r � Filler.Material (Below 501 TY SEPT C RK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f j available within 200 feet.) v Installation wills : Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of a . Water table depth t. SEPTIC TANK ❑ Type/Mfg L('l Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We Foundation Property Line l , LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line •i SEEPAGE PITS 1] Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property DISPOSAL PONDS ❑ _ _ s 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 r 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 lays 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 Iaws of Calif057t , { a The applicant st all for all re uired inspec Complete drawing on re)mPriqe side. / , Signed Title: nPs Q�.C! '/� /zJ_ lxe� Date: —.-`_� FOR DEPARTMENT USE ONLY Application Accepted by k Date i& ALTH rea #` Pit or Grout Inspection by Date [ Date Final Inspection by ! Additional Comments: F ENVIROA; HEDIVISION ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83x6385 l I Applicant- Return ail copies to: Environmental Health Permit/Services 1,601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED r CK RECEIVED BY x INFO _ _ 1}{ r DATE PERMIT"NO. + EH 13-24{REV.1ias) QJ ,.,-.o�y\ Itr[ �i LJ4t� Eft 9428 J_.-.�