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• ,a _ a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 's 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 MAR 12 1OvM0 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROWAIENTAL HEALTH PT-_,`N �1/0 EPVi_'ES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein escri ed.`fiNs app icatmn 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 9 30 VkTO'Z GZo -R City Loo I Lot Size PM F.WILTS OIL CaMP C/o r+#,.ZA V(,E WOOL XY Owner's Name Wea DrLCoMpfkNH Address Ib(, rti/tNf4lf�fsSTCtRct STotltrorJ 9Si0b Phane<I09)94$-9Stl1< Contractor a.1SC"t,Iif *)MF►�ffltr �I a Address(4(411 Cb}Il1STI Sr,FIQ W4r CA Wile License No. SS8zo5 PhonITS)bSq'"tJ TYPE OF WELL/PUMP: NEW WELL X 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 W ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation lI Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Sclia z`44 Pyr__ _ Specifications Cl Public %OthertAarlitofUK6 Ll Delta Depth of Grout Seal 0"-Is Type of Grout ADIT _ i I Irrigation 60-Approx. Depth l I Eastern Surface Seal Installed by (b.9TAAtM(k _ Repair Work Hone 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet./ C> Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms ( S Character of soil to a depth of 3 feet: Water table depth v/ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PET. ❑ Method of Disposal C 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 I Depth Size Number SUMPS Ll Distance 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 DiMrict. 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." The applicanS rLiu t call for all req irod��pe.-ct}ons. Complete drawing on reverse side. Signed X GG�x!! �C►fitrt �� PM^( Title: PAOJMT Date: �/B/qQ FOR DEPARTMENT USE ONLY Application Accepted by /' " r�t Date 41th 6 Area Pit o Grou nspection by _l7ti^ti Date *i�'l Q�Final Inspection by 1!I�1 r Date S Additional Comments: -AS1 Ali G✓-G� a ! ell ❑ 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, Silk., CA 95201 ,T FEE * INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY HATE PERMIT'NO. 1 3790 a.EH 13-24(REV.4/H 51 D �� "4114�� /may Y EH 14-26 / �