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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . /� Job Address�Gd7CM25c]1��A�� i7 @ 2 t�1 I Z 1,�4"L - City IRAC1' Lot Size PM Owner's Name KiMCA 1+ cb�_5 AddressRL' o O X 38 Phone At K I 00 Contractor Ad res License No.4@0111000e TYPE OF WELL/PUMP: W WELL 71 , "1cuWEL REPLACEMENT [7 DESTRUCTION [{lS-(n$�j rJYG 'S PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERCpE�T�CNN\CRi1N(y� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS to ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of WeII Excavation Dia. of Well Casing❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casi . Specifications ❑ Public t� Other ❑ Delta Depth of �VSp-70 FF Type of Grout � I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Q Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i 1 DESTRUCTION { I (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 p Character of soil to a depth of 3 feet: Water table depth M SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmentsi PKG. TREATMENT PLT. ❑ Method of Disposal 3 � Distance to nearest: Well Foundation Property Line fi ff) LEACHING LINE ❑ No. & Length of tines Total length/size S O FILTER BED ❑ Distance to nearest: Well Foundation Property Line D SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." h The applicant must all 11 re i d inspections. Complete drawing on reverse side. Signed Title: 6rARF�hINCCP__ Date: S FOR EPARTMENT USE ONLY / Application Accepted by Date Area I Pit or Grout Inspection by Data f=inal Inspection by ate 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 MOOjU�NT REMITTED CK-CASH RECEIVED BY DATE n /PERMIT-NO. r EH 13.2g(REV.t i x 51 �/ �( � � C/O �]r^l5 EH 1q-28 �