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. APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y rr• (Complete in Triplicate) 7: 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 theMet abd Regulations of the San Joaquin Local Health District. U)ELL;;''')ln'I– 2G`d¢,,., !� / L 1 / v�, Job Address SIM DS crn f apeC yI-U5S Rd 5• end Gr� OCty� .LoL Sue�� PM _ Owner's Name S1ImPSmti— 1 Lj�-r-(2C. Address PO' (3CX 757T _ �r CA 95366 Phone 59q- !'2'11 �� f� t� -- �+ q Contractor PI IC� Ln fl �� Ilt Address Pa c, AH-0 (!A _ License No. ZE3�C55 Phone 328–g 11 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)XMcmtc'rt o9 We 11 DISTANCE TO NEAREST: SEPTIC TANK Nf} SEWER LINES > /0C / DISPOSAL FLO. ^'14 PROP. LINE >SO FOUNDATION NA AGRICULTURE WELL NA OTHER WELL/GOO / PITS/SUMPS /JA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /r'1C Dia. of Well Casing C./l ❑ Domestic/Private �(Gravel Pack C Tracy Type of Casing to Specifications �1 (1 Public fl Other n Delta Depth of Grout Seal �SG/ / / Type of Grout 6P Irrigation 2�/ �QrApprox. Depth 1 I Eastern Surface Seal Installed h, i�L�1-Q-t- D r t ll l n —ZT�— Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I ! (No septic system permitted it 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. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 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 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-contfacting signature certifies the following: "I certify that in the performanca 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 required inspections. Complete drawing on reverse side. Signed x ,�5a)0— Q �yc(-�C� R G, Title: / s¢nfuu�iUeDate: 0 2Z 1 FOR DEPARTMENT USE ONLY �nf` Application Accepted by alll Date Area Pit or Grout Inspection by ie -` Final Inspection by Date Aoditional Comments: ❑ Stk 466-6781 C Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,�P. . Box 2009, Stk., CA 95201 (I) 1caA5A Ne4dz i9i.' o a Cv. cu rtti 6 7/msci%_ Paper, AA �-e� t as FEE AMOUNT DUE AMOUNT REMITTED CKs RECENED BY DATE PERMIT ND. INFO CASH