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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAH 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 _ a) A g r T/.0 fn a L-7 City G�r , Lot Size ��U_x 2 PM I Owner's Name Address � CJ "'y /�- YOO Phone 72- 3 SXI lr•�-5rf4 tw.pIff— _ Contractor Address TZ�}/4�j 6^4k OJ License No. I Phon TYPE OF WELL/PUMP: NEW WELL % WELL REPLACEMENT ❑ DESTRUCTION 0 elf.15 :z PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP_ LINEee FOUNDATION AGRICULTURE WELL OTHER WELL PITS.SUMPS�i0ltr7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /� ❑ Industrial ❑ Open Bottom' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 04 Cwauel-4ackgr�) ❑ Tracy Type of Casing 15M*4114e �fC7 ��L Specifications C1 Public. n Other n Delta Depth of Grout Seal Type of Grout 114e6?1Lr meo1- ""'g �_Appfox.'Depth I I Eastern Surface Seal Installed by �o�h�e 4 faY- 7`r�+yr♦t ^'-t�/G® f n,pA, ri - ., epair Work Don . . ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter 11 r. Sealing Material (top 50') 17"f� "f ,`��?!}. -7D�B�11PX Depth L2 X Filler Material (Below 50') �3� -7d 7Z ' tel ;' ;� ie� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if 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 T Foundation Property Line ` 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED U Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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."Contractors 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 req ' • spections. Complete drawing on reverse side. ` Signed X Title: 4- • C.s-o% ! 14- Date: A/ FOR DEPARTMENT USE ONLY r� Application Accepted by Date � Area twzr LIC Pit or Grout Inspection by Date Final Inspection by Date t Additional Comments: f ❑ Stk 466-6781 O 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 A / r uo FEE AMOUNT DUE AMOUNT REMITTED rt tc BY DATE PERMIT NO. INFO CASH . EHS324iAEV.r/h51 E11 14•26 I