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APPLICATION FOR PERMIT t GT SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED 1601 E. HAZELTON AVE., STOCKTON, CA etc` / Telephone (209) 466-6781 C� 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 Local Health District. ♦pElP �wio� Job Address 7 AZ&YL,F k12 CityS P'lJl 19T Lot Size y eO Y/lf 7 PM q--5( y55 Owner's Name J"�CRiPY IdZA66,9771 Address Z lZe) iAli i G e-) J,QO Phone Contractor's Name Mo1')k'MA 11 14&gt A cense No. 2 Z6 Z6 Phone /- 3.2 ID TYPE OF WELL/PUMP: NEW WELL (�t ANaLL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION 0, SYSTEM R AIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK /QE)} SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4S22f- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /Z Dia. of Well Casing ;9Domestic/Private WGravel Pack ❑ Tracy Type of Casing 1?10f_ Specifications C L Ib/J ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ,'$'D -o- Type of Grout ❑ Irrigation 242nApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump SULi H.P. X.Z. State Work Done 6 Well estruction 11I Well Diameter Sealing Material (top 50') Si X /JJ�f O Depth Filler Material (Below 50') ``��-/T..Y//P}}E OF SEPTIC RK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ,Apt y��'i� l�J�� available within 200 feet.) Ilnstallaamr! li lI serve: ,seri ce_ Commercial_ Other z 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 T PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size T 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, andr- 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 rrrus��9�t call for all required inspections. Complete drawing on reverse side. Signed X //Ky!3�; J7/Jfl9cs¢�� Title: �/ /S Date: FOR DEPART ENT USE ONLY •�/7� Application Accepted by AAo / l -,Y Area 2 Pit or Grout Inspection by e V Final Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CCArH INFO AMOUNT D E AMOUNT REMITTED RECEIVED BY DATE PERMITNO. EH 13-26 IREV. 1el8R1