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APPLICATION FOR PERMIT � = SAN JOAQUIN LOCAL HEALTH DISTRICT kJAYMEi,4 , 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'JUL Q 6 (Complete in Triplicate) ; FNYJ9WAAEWd&bMfriVpplication is Application is hedeby made to the San Joaquin Local Health District for a permit to construct and/or install ttippQf{�h San Joaquin made in compliance with San Joaquin County Ordinance No. sewage or No. 1862 for well/pump and the Ru�� Local Health District. Ild � Shame A-cmy Depot ctyZathrop Loc size _ 800 aC • � PM Job Address - Roth Rd . T athro-o Phone C a. Owner's Name " ArTly Address - — P.O . Box 108 �ontractoNorth Valley Drill(&6ss Corning Calif 60,Uense No. 88 Phone —c 97 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ `r PUMP INSTALLATION 1-1SYSTEMREPAIR 11 OTHER V M0�11 / tis E EI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �� « FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casio tl nIndustrial ❑ Open Bottom M Manteca Dia. of Well Excavation 0 Ft g ❑ Domestic/Private IT�Gravel Pack C3Tracy Type of Casing SCh 40 nVC Specifications `"1 Public ❑ Other ❑ Delta Depth of Grout Seal Varig Type of Grout i' am Cb S .I I irrigation vari(p,pprox. Depth t ) Eastern Surface Seal Installs Bo [A !Repair Work Done ❑ Type of Pump -H.P. State Work rk Done D y. Sealing Material Ito 50'1 I Well Destruction ❑ Well Diameter g p IMoilitoi?ing Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i 1 DESTRUCTION i 1 available within 200 feel(No septic system 1tled if public sewer is Installation will serve: Residence— Commercial_ Other ' Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: S Ca ' SEPTIC TANK ❑ Type/Mfg pacity No. Compartments Method of Disposal PKC. TREATMENT PLT. ❑ rt 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 l 1 Depth Size Number SUMPS ❑ iy Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ f i 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. certify that in the performance of the work for which this permit is issued, i shall not Home owner or licensed agent's signature certifies the following: "l 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." The applicant m st tail for ail required inspections. Complete drawing on reverse side. � Signed Title: 3 f FOR DEPA U LY Ar C` I yd Application Accepted by Date i -10 Pit or Grout Inspection by Date r� Final Inspection by Dater! 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 i FEECK RECEIVED BY DATE PERMIT NO. INFO FI Ll AMOUNT DUE AMOUNT REMITTED CASH r +.EH 13-24(REV.Iin51 EH 14-26