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• APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1\101SIA10 H11V3H 1V1N3WN0211AN3 SANJOAQUINCO 1601 E. HAZELTON AVE., STOCKTON, CA S30IAN3S H1.3V3H�I'18nd UNTI'-PUBLICHEALTHSFt AUAMe (209) 466-6781 �1NnOJ NInOVOf NVS ENVIRONMENTAL��pprr��L�pp7� TR T q T __EA111 RNII�T_iTNIRES 1 YEAR FROM DATE ISSUED Q66� £ � d�;'',.J da ClI�L a ' Ml y (Cornplete in Triplicate) 43AI333a Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work�,n�T,t',e.�l,�,,r�tls ication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regula ti 1 o}'the San Joaquin Local Health District. C C T ;�� \, Jab Address 82-51l S L �-E U LN 1 V'9 1 1'.i-� City TKAC 7 Lot Size I t� !1-ra c,t l t� ,7 t� �-- `t I PM Owner's Name PIA"OD PQCRE-0 ES Address DCK-l'}�t)�� 9-N �&3 Tc ,r��-,,.y �7 (� �a /�� y� tI Phone A Contractor F-7�✓IKl'��Sr Ll.�1/l'F-Ir3N--Address��L�_K.,V�.�Y3-M Cl3 V1-�lvy�R �� 11C _�. -7 C License No. _Phone- S LI TYPE OF WELL/PUMP- NEW WELL WELL REPLACEMENT , I DESTRUCTION ❑ PUMP INSTALLATION CI 4MDUIlaK,tt�E,rtE1kS SYSTEM REPAIR LI 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_AR_EA CONSTRUCTION SPECIFICATIONS LlIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ~ LD7y �� Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack PcTracy Type of Casing—SC-1A40 PV/�- ❑ Public5— Specifications�j� Tn T1� �r ❑ Delta Depth of Grout Seal 'rte cL-v Ty of Grout Dt-N'V (t F- CI Irrigation pprox. Depth ❑ Eastern Surface Seal Installed bIv7rLtc17 Repair Work Done ❑ Type of Pump H.P. _`ttS,-ta�tey�W�ork Done UN t(U Ne Wt9-LS Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Bores r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Il REPAIR/ADDITION I.I DESTRUCTION Cl INo septic system permitted if public sewer is blith2l Installation will serve: Residence— Commercial_ Other availae win 00 feeL Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. E 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 Foundati DISPOSAL PONDS Elon Property Line I 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, 1 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, 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. Signed Title: Date: s� 3-I Date: R DEP ENT USE ONLY Application Accepted by �d 33 Date L/ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 CK ' INFO CASHRECEIVED BY DATE PERMIT N0. j EI1 1126 IflEY.1/es) C i L )) / 7 `- —//-10 l�S/Y