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iCA. , t , �cN°�� N APPLICATION FOR PERMIT X, '4 SAN JOAQUIN LOCAs. HEALTH DISTRICT PAYMENT RECEIVED vpGP �P�� 1601 E. HAZEL T ON AVE., STOCKTON, CA ave E��P Telephone (209) 466-6781DEC 1 P�\J RQC1 � � � 988 PERMIT EXPIRES'l YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRQNMElklT'+r L'7ALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thNgolkdm)k)db�d. 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.tr Job Address 1 L O 'City_ LQL91 Lot Size PM 1Z13i3EfLTS Ou-CaMPA.ry %3lcuce wao;SGY Owner's Name AogLG0SPI Address 1164 K VE l{ Lw ST6s Gh R �2Oq� /Z� Phone ms s,/, rr *538 Contractor VC Addressw (,f{�P1S ){, License No.AI T ZY Phone r0'/ TYPE OF WELL/PUMP: NEW�WELL'- AW._y WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ID Manteca Dia. of Well Excavation - 114CA Dia. of Well Casing ❑ Domestic/Private LJ Gravel Pack ❑ Tracy Type of Casing -5c- 40 P�C Specifications L1 Public `XOther 1q� i 11IT00-0 Delta Depth of Grout Seal -SS-F£e-r_ Type of Grout ±tM (� ❑ Irrigation -3�5 pprox. Depth ❑ Eastern Surface Seal Installed by L �J Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') v Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) , Installation erve: Residence_ Commercial_ Other Number of living un . Number of bedrooms Character of soil to a depth o et: Water tab) pth SEPTIC TANK ❑ Type/Mfg Capacity N mpartments j PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well dation Property Line LEACHING LINE ❑ No. & Length of lines Total le ize FILTER BED ❑ Distance ton Well Foundation Property Lrn SEEPAGE PITSepth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL ON DS ❑ 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 performance of the work for which this permit is issued, i spa er�q �q�1s s tion laws of California." J�Iy JAL1lI`JiJAL 1 ttA I t1 llIJ 1C The applicant must call for all required inspections. Complete�dpraawiinngg on reverse side. ENVIRONMENTAL HEALTH DIVISION Signed 916 '"Tale:' S 0 6�— SPEC t1 LlP 11 FOR DEPARTMENT USE ONLY /� Application Accepted by ff �j Date & _ Area Pit or Grout Inspection by Date ' D if Final Inspection by Datey Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q 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 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 1324(REV.i/n5) •" 1� �� EH 14-26 / /