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APPLICATION FOR PERMIT f r SAN JOAQUIN LOCAL HEALTH DISTRICT 11 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED d. (Complete in Triplicate) Application is hereby made to the San Joaquin Lacer Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Cou ry Or IQa a No: f sewage or No. 166 r well/pump and the Rules and Regulations of the San Joaquin Local Health District. fj�/�r �� 2 ?' / G' City Age 91 ,ft Lot Size PM Job Address I,C CKGs ' OWfIC nCr Address OWCat'r'L/1 �wVdYl Owner's Name 1�11��g MV = Contractor -6 /C Addressz Z EM t"S'(` License No.1aZbf� Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ �, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER g ..�7 7 7/`- borrVz DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS it i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - f 1 Public ❑ Other ❑ Delta Depth of Grout Seal T pe of G�ro�L+I ISI Irrigation _Approx, Depth I I Eastern - 'Surface Seal Installed byGFT7�t 'w Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material (top 50') ��t G - Depth Filler Material fBelow,50'1 e41COflIL 6 a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I I INo available septic sysm m permitted if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms " Character of soil to a depth of 3 fear. Water table depth " SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal n Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line :57— ' SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring c so contracting impe sa 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 compansa-�i tion laws of Califo ia." Z The applicant c for all req din Y S. Complete drawing on r rse side. Signed X- lo& Tide: ✓ Date: /�/� FOR DEPARTMENT USE ONLY may" (Application Accepted by�4 �'�/� — Da[ Area�{:j�,l—__--,- - -� Pit or Grout Inspection by pate Final Inspection by Date Al jaZI ' Additional Comments: Ill ❑ Stk 466-6781 ❑ Lod ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 RECEIVED BY DATE PERMITNO. 1 INFO ' aEH M24(REV vxm� EH 11-2e 4