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' '•✓ 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 (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 3S N. CNEQoKse LAma City Lops Lot Size PM Owner's Name Geeta., 01 L Lo Address );k CD Sr- 46N EM p 1 Phone201 .2 -dZy I n�4n� //X�o2q�++v F?fr+oroT Gni 4'cs�y H�odo Contractor AParFn leo-S1=TEMI Address y3.?Z' A License No. 612 4 Phony / Gf!-1 o TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ tJov%,I_o,.t,%f t r�lj 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 Bottom ❑ Manteca Dia. of Well Excavation _$11 Dia. of Well Casing ?u ID MONtrn%H� W&L Domestic ovate X Gravel Pack ❑ Tracy Type of Casing -<r-1. t10 PV Cr Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ .2S" Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by 0410e4JAP6 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter 2 Sealing Material (top 501 Depth (0o of Filler Material (Below 501 F SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewe available within 200 feet.) Installation will se Residence_ Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: or table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. & Length of linesength/size FILTER BED ❑ Distance to st: Well Foundation Pro Line SEEPAGE PITS Depth Size Number SUMPS El to nearest: Well foundation Property Line AL PONDS ❑ I hereby certify that 1 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." Contractor's 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 must call for all requir d inspections. Complete drawing on reverse side. Signed X Title: Psitof 1_/_0 Date: 11/18' In. FO P T NLY Application Accepted by Date Ar 2 Pit or Grout Inspecti Date_ Final Inspection b Date C i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3621 O Manteca 104 ❑ Tracy �� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH13-24 IREV.1 8 5) 3J OU _Z r EH 14-28 J .00 IG.w `^ 11okj v�o��St