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APPLICATION FOR PERMIT 4.rJ JOAQUIN LOCAL HEALTH DISTRIL",w-' PAYMLtIVT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 MAY 09 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE 13� ��lqo (Complete in Triplicate) PUBU�OAQUIN COUNTY � BLIC HEALTH SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inEfall tRLr'„Vb'Mc'M1 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules andel Regulations of the San Joaquin Local Health District. / d l ''-- II .{�. Job Address �/ "1/, a'� fit/ City_T�Y Lot Size PM Owner's Name (+tIQ$�pin 67111-�P P2410Address ;D 0- �OX a C/-S±C,�# 7S,�2 Phan a1 Contractor S/C� Ck ��^,f/.'r, Address 7)0 Rex 1/43/ A.,d,[ry/n 9�53S2 Lv!� icense No. 16/7 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 60r1i _ DISPOSAL FLD. PROP. LINE 2700 FOUNDATION AGRICULTURE WELL OTHER WELL .20" PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation $ v9— ❑ Domestic/Private �i9_Gravel Pack Trac Dia. of Well Casing Y Type of Casing P✓G Specifications I I Public (1 Other 11 Delta Depth of Grout Seal y I I Irrigation Type of Grout 41' __ Approx. Depth I I Eastern Surface Seal Installed by s/�>'+A J1.�i//rte_ Repair Work Done ❑ Type of Pump H.P. - State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Mn^rltj�t� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence No within 200 feet.) Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well F on Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size __ Number SUMPS 1_1 Distance to nearest: Well Foundation DISPOSAL PONDS n 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 D3trict. 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: "1 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 al required inspections. Complete drawing on reverse side. Signed X n �/ v�— !a' Title: J�G^irr Ce/pbr7' Date: S�y/QCT FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O 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 REMITTEDCK INFO CASH RECEIVED BY DATE PERMIT'NO. EH I12N IREV.I/x s) EH 1628