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APPLICATION FOR PERM1. 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 Local Health District. Job Address O Jti+ cne-MKEe, 'I City `�0�1. Lot Size PM Owner's Name �� Kra- s�f - Address �1 Gys rn KeC • Phone 41 Untp5- `-7 Contractor's Name KlrinF��r1er a �, `)OS_ License No. �n4 ()IhW hAJ1,M Phone �� s 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 �7t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PV Ci Specifications 13 Public ❑ Other ❑ Delta Depth of Grout Seal --,725 X Type of Grout ❑ Irrigation 6-0—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump oT H.P. State Work: one Well Destruction ❑ Well Diameter d Sealing Material (top 501 11�cl� Y z(1e1(C7Depth Filler Material (Below 501 TYPE OF SE IC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Capacity No. Compartments 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 ❑ 1 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. rye )r� p Signed IUIU Titla:sm t1U(. royc0t1�115� Data: 6V �'OS R EP MENT USE ONLY Application Accepted by Date '7 ea Pit or Grout Inspe t by Date , - Final Inspection by ' Date/d -30-x.5 Additional Common ❑ 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE PERMIT NO. INFO ,o,m, 1 •L-(-.), - ql . /t - - (0/)J .cr GG_t'% n�