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APPLICATION FOR PERMIT j OAN JOAQUIN LOCAL HEALTH DIS*T 1601 E HAZE i ON AVE , STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) 00 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 mdde In I-omphdnce with Sdn Joaquin County Ordinance No ',349 for sewage or No IB62 for welllpump and the Rules and Regulations of the San Joaquin Lol31 Health Di51nCt Job AddressKOQ — — City �7 Lot Size I-/Z ' 3 PM — _ f� 5'a t-t° 2Trr 7 l Owner s Name AC f r=IL �- Address 3�4 /'I~� I �j�eti a L')(3 Tr_ Phone SLG^ � 001,,41_1 1 COnlracter 00 , x e'W% Is Address 1- 1715 CA License No�f S � Phone L`7 TYPE OF WELL/PUMP NEW WELL 0 WELL REPLACEMENT L] DESTRUCTION t_l f<`iiPt_6P-a`t1V. $e Fi�L F PUMP INSTALLATION I l SYSTEM REPAIR 11 OTHER X DISTANCE TO NEAREST SEPTIC TANK �V.4 SEWER LINES .2 a f DISPOSAL FLD — PROP LINE FO FOUNDATION 10 AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial IJ Open Bottom L-) Manteca Dia of Well Excavation . Dia of Well Casing i i Domestic/Private I 1 Gravel Pack Ll Tracy Type of Casing N01" �- Specifications i Public 1101her ha ni�r+ I 1 Delta Depth of Grout Seal F'// .r 4 h Type of Grout r i 11 Ifriy.ition ��Approx Depth I I Eastern Surface Seal Instdlled by s Repair Work Done I 1 Type of Pump _nI�a e H P Stale Wprk Done Well Destruction i J Well Diameter 8 Sealing Material (top 50 1 -.- Depth Filler Material (Below 50) TYPE OF SEPTIC WORK NEW tNSTALLATION I i REPAIWADDITION I I DESTRUCTION I I (No septic systam permitted of public sewer is available within 200 feet I 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 L1 Type/Mfg Capacity No Compartments PKG TREATMENT PLT 1 1 Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE I 1 No & Length of lines Total length/size FILTER BED I I Distance to nearest Well Foundation Property Line SEEPAGE PITS 1 I Depth Sire _ Number SUMPS I I Distance to nearest Well _ Foundation Property Line DISPOSAL PONDS I 1 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 performance of the work for which this permit is issued, I shall employ persons subject to workman s compensa tion laws of California The applica must call for all required inspections Complete drawing on reverseC�s�iide Signed X e-' �L Title 010 d C. Date FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments OStIk(� 466 6781 0 Lodi 369 3621 O Manteca 823 7104 0 Tracy 835 6385 Applicant Return all copies to Environmental Health Permit/Services 1641 E Hazelton Ave P 0 Box 2009, Stk CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK Alf—CASH RECEIVED BY DATE PERMIT NO /1(R � a . EH137EV i+Mtir EH 14 26 J