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s APPLICATION FOR PERMIT ,;. SAN JOAQUIN LOCAL-HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ' t� PERMIT EXPIRES 1 'YEAR FROM'D ' ATE ISSUED Y ,, . (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct ad/or install the work herein described. made in compliance with San Joaquin.County Ordinance No.-549 for selvage or No.'1862 for well/pump and the Rules-and Regulatioof he SanllJoaquiis n Local Health District.. . Job Address 75 West Valpi`Co` Rd - � ry City .Tr'acey Lot,Size PM Owner's Name Ge o '" . AddressPico Rd - Phone Contractor's Name�rrlrl 1111 �^te 3 ,qr �_n_ni icense No. 2 9(14-48 I TYPE OF WELL/PUMP: Phone _ NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ SEWER LINES OTHER ❑ Gam} j L FLD. PROP. LINE FOUNDATION. � - .AGRICULTURE DISPOSAWELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Ria. of Well Casing 1,Y� Gravel Pack 7S Trac Type of Casing ❑ Public ❑ Other S.z' y Specifications ❑ Delta Depth of Grout Seal r 76 ❑ Irrigation I-s�pprox. Depth ❑ Eastern lqf �uP2TYPe of Grout � Surface Seal installed by Repair Work Done ❑ Type of Pump H P Well Destruction ❑ Well Diameter Sealing Material (top 501) State WorkDone mlk 71-CO TD JDepth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence— Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet- SEPTIC TANK a ❑ Type/Mfg 'Water table depth Capacity No. Compartments I PKG. TREATMENT PLT. ❑ ' Method of Disposal rrI - 67dot~ Distance to nearest: Well Foundation -0 - � Property Line �„ rt•, LEACHING LINE ❑ No. & Length of lines FILTER BEDTotal length/size �/ ={ ❑ Distance to nearest: Well Foundation Property Line C r _ ,,SEEPAGE PITS _ ❑ Depth _-SUMPS Size Number_ m � Cil ❑ Di Distance nearest:' Well Foundation DISPOSAL PONDS ❑ Property Line -•f -1 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."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," 3 The applicant qNskcall for all required inspections. omplete drawing on reve aid . Signed Fs: Y Y\.(L'` Title: Date: 4-�Q-8 t � FOR DEPARTMENT USE ONLY Application Accepted by aA6 - .117Date d� Area Pit or Grout Inspection by �` - � s/-�j Date Final Inspection by, Additional Comments: ff i�'7SiDate El Stk 466-6781 13Lodi- 3W362r ❑ Manteca 823-7104 t fra 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 INFO CASH RECEIVED BY DATE PERMIT"NO. +EH 13-24(REV.lot 3� EH 1428 s . � 3ds-