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7 ro-" Weit.. c d- �° APPLICATION FOR PERMIT lV SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE:, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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 r Local Health District. Job Address v �J�'i/✓t/ City NA4114M9 Lot Size PM 7 .L k 4A/ Phone ` y8� Owner's Name �C3 RIG k/V E.L L Address Contractor's Name C' , EJY`7 I/ f� " 'License No.l(� ""Phorie' ✓ TYPE OF WELL/PUMP: NEW WELL-1K .*WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION �J A- � SYSTfEM_ ,>RE'PAIR�OOTHE6 ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER_LINES L 'p /�11'I�� DISPOSAL FLD PROP. LINE ,�/ _ FOUNDATION _Zig AGRICULTURE WELL Nk OTHER WELL ® PITS/SUMPS � � f - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom W Manteca Dia. of Well.Excavati n /A Dia. of Well Casing _ Domestic/Private 1 T Gravel Pack ❑ Tracy Type of Casing-1 VC Specifications Glass C] Public ❑ Other ❑ Delta Depth of Grout Seal ��' Type of Grout : C.0 NI ❑ Irrigation, ,15.-��Approx. Depth ❑ Eastern Surface Seal Installed by cl_ / 9 Repair Work bone ❑ Type of Pump H.P. State Work Dane Weil Destruction F1 Well Diameter Sealing Material Itop 501 ! Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' I available within 200 feet.) Installation will serve: Residence Commercial_ Other f li Number of living units: Number of bedrooms •� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments 11 PKG. TREATMENT PLT. ❑ Method of Disposal 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: - - Well Foundation Property Line DISPOSAL PONDS ❑ �- I hereby certify that I have prepareclAhis 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:-"bcertify 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 applicant ust call for all required inspections. Complete drawing on reverse side. II Signed>{ { U Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date' �_ Area Pit or Grout Inspection by ate -I-86 Final Inspection by — --Dates Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 XMenteca 8217104. ❑ Tracy 835-6385 - Applicant Return all copies to: Environmental` ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED t+CA(S�H�. RpCyE�IVED BY �[ DATE �P/E�RMIIT"N0. + EH 13-14(REV.10/831 \Q� ({ b 7 IV�d -( ��Lj�YZ EH 1426 J