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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,( Job Address .S37S Z-:: �>tiG7%�.P �� City- CAMP C Lot Size 6f) AR6 S PM Pwner'a Name �t.0 €Ufy-Ali- �J`rC Address S�7S �.�E4-7",e RJ7 �Q 1 7E Phom 3 f s Bl! QRl[LliUCv UM hefmf aC,+ 3767 6f Contractor S Address a00 EL rE/l, License No.e-_S'. C=6/phone 33 -0299 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENTX DESTRUCTION fi� PUMP INSTALLATION W SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES /60 DISPOSAL FLD. PROP. LINE =a 70 2 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ ' Industrial Open Bottom ❑ Manteca Dia. of Well Excavation a E Dia, of Well Casing >r Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing KR/ - Lc7€GL Specifications pp\� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .SO r Okes Type of Grout ❑ Irrigation I,',Q'_Approx. Depth El Eastern Surface Seal Installed by Repair Work Done E3 Type of Pump // / .1 H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 501 95K 64O4f-r Depth 1a Filler Material (Below 501 s4/wo 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 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS [IDistance 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 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 pe ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tionlaws o IH rnia." Thea m st or all re Ire in ctions. Complete drawing on reverse side. -1 Signed ¢A�� Title: t l�10/2 Date: .0 —�� FOR DEPARTMENT USE ONLY X�/ Application Accepted by Date �.-. /_�1` �`' Area Pit or Grout Inspection byre Daatte �' T A Final Inspection by Date Additional Comments: .([E'/Y�J T.�wr.T R"L,.7irL�aO�pG' r•' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-A617 ❑ Trauy 8356385 Applicant- Return all copies to: Environmemal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO MOUNT DUE AMOUNT REMITTED I CASH K* RECEIVED BY DATE PERMIT NO. • EN IREy.t/951 EN WA l !! D v Z�� /l✓1 —�G—O p Jbsrr— �7J / OZ