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1Y i L APPLICATION FOR PERMIT : SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p (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 f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address } City CkM Lot Size 4�C sit t!_C PIN pp ii -ell !� Owner's Namex 1--1 GrIQ c9 Address Phone Contractor / �i 7i Address_ C Z a V- t rLicense Nor-- TYPE -TYPE OF WELL/PUMP: F . WELL WELL REPLACEMENT.❑ DESTRUCTION PUMP INSTALLATION ?< SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONSPECIFICATIONS ❑ IndustrialOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f� Domestic/Private LJ Gravel Pack ❑ Tracy Type of Casing r ` Specifications p Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout liLS4 deb, LJ Irrigation ,tApprox;Depth ❑ Eastern Surface Seal Installed by V4 rf® `" Repair Work Done C1 T of Pumpxs;?��H.P.' ; ' ate Work Done__ T — .� _ (Well Destruction >( Well Diameter �a Sealing Material (top 50') ID I n f- Depth Q6D Filler Material (Below 50') TYPE OF SEP-TIC,WORK:?a NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is •" } available within 200 feet.)- j 1 Installation will serve: Residence Commercial_ Other i r Number of living units: � Number of bedrooms Character of�soil to a depth of3feett: Water table depth l � J SEPTIC TANK — ,Ij xType/Mfg Capacity No. Compartments .%,.,RKG. TREATMENT PLT. ❑❑1 Method of Disposal j Distance�"to.nearest: Well Foundation Property Line �� f I LEACHING LINE ❑ No. &;'Leng'th of lines;' Total length/size 3 . FILTER BED EDDistance to-nearest' Well ' Foundation Property Line a p SEEPAGE PITS ❑ Depth •- I Size Number z ' SUMPS ❑Ll Distance tto._nearest: Weil Foundation Property Line "A �. r, f DISPOSAL PONDS ❑ ` v I hereby certify that I have prepared this application,and that the work wRIL'be done in accordance with San Joaquin county ordinances, state laws, and S rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certirfy that in the performance of the work for which this permit is issued, Pshall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting sig"nature i 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 cbmpensa- Ln laws"of California." The applicant must call for all required inspections4omplete drawing on reverse side. ! s Signed Title:sR P Date: �A-3 FO DEPARTMENT_ USE ONLY I Ipplication Accepted by Date Area Q Rit or Grout Inspection bDate( Final In � ..�.,t spection by Date Additional Comments+ � b I - Stk 466-6781 Lodi 369 36'1f anteca 823-7104 ❑ Tracy 835_6ft5J Applicant- Return all copies to: Environmentai Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFO AMOUNT D E AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13d41REV.tie al EH 14-'28 Z I r ��Dt3 7tGti