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V " •'� APPLICATION FOR PERMIT 'A' SAN JOAQUIN LOCAL HEALTH DISTRICT pA- A EV 1601 E. HAZELTON AVE„ STOCKTON, CATelephone RrGG ' i 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NQV i H (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to Cpnstruct and/or 7stall t�►lnto ¢��tn�E ccr bed. This application is made in compliance with San Joaquin County Or �I sb��- tg" �} ct] f r py4 (}t lv1fAALif6rT�JrSIT and the Rul nd Regulations of the San Joaquin Local Health District, ENVIR®NMcLN�,t.t i EALTH DIVISION Job Address s s. ,SurrF�2 SPEC." L PERM City 77V G1e77*ry Lot Size 464ockPM Owner's Name 1541) �?/9 dUic/JX Address a a a 4.e Phone - 36 7 Contractor .S�Ea77CAddress P7?a a f eLJ--,Y/en-6 License No. S/a�6.8 Phone TYPE OF WELL/PUMP^ NEW WELL ❑ 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 861tom ❑ Manteca Dia. of Welt Excavation d"'-.1-J rr Dia. at Well Casing ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing_ F I!f.. go H 9U Specifications FPublic Other n Delta Depth of Grout Seal D z�o�t/z Type of Grout. �E�n►v� _ X Mr/vjmretA lr3a Approx. Depth I I Eastern Surface Seal Installed by RF- wEsTc»v 2,r„G r SpEC-17f�,y Ged�r —• Repair Work Done ❑ Type of Pu- Nf _ H,P. �//1' State Work Done _ r n Well Destruction . ❑ Well Diameter f Seal#ng Material (top 50') �d Depth _ 36 11h0,0 c7x Filler Material {Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION.1 I REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceL Commercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distant; to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Ltength of tines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line ! I I SEEPAGE PITS I I Depth Size _ , Number i SUMPS 11 Distance to nearest: .. Well Foundation Property Line DISPOSAL PONDS L7 I hereby certify that I have prepared this application and that the work will tie 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 campensa tion laws of California." ( y SAN 1QAQUIN LOCAL HEALTH DISTRIC`f The applicant must call for all required inspections. Complete drawing on reverse side. ;; �ENVIRONMENTALH �!L Q!VlSipN , Signed X � Title: 2.Zc7" oy,,4ti 4ff"e- S6QQ'f FOR DEPARTMENT USE ONLY Application Accepted by �� -°- 22,60 Area Date i / Pit or Grout Inspection byDate/ " Final Inspection by pate Additional Commants: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECFIVED BY rNf p H DATE PERM17'Np, EH 21iAEv. 14 FH 14 26 t ,7 � CW- 5Z _3,1§