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APPLICATION FOR PERMIT P I SAN JOAQUIN LOCAL HEALTH DISTRICT �VeG ' 1601 E. HAZEL i ON AVE., STOCKTON, CA t,1 f q', Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. ( OctJob Address _ 4-2-CA- I,Jcs+ U0 eA Strf e am_ City Lt t Lot Size I. t °X1::S PM Owner's Name &Y C t dry Address +2- W et-I Lak,!,4;4 St. S*- Phone 2,a 30- 6 f I__ i L.pG�t f Contractor SQ M EXPJof�-T!O Address 8�S t- Myr—fl[, 56ckloffaLicense No.C5 -5122-(-$ phon�?o`��`��-QG11 TYPE OF WELL/PUMP: NEW WELL)K Z WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION v AGRICULTURE WELL — OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C2 Manteca Dia. of Well Excavation rr Dia. of Well Casing 2'r ❑ Domestic/Private ;K Gravel Pack ❑ Tracy Type of Casing rvG Specifications f'1 Public M Other I-1 Delta Depth of Grout Seal 40 _ Type of Grout599 r I I Irrigation 55,Approx. Depth I 1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump NA H.P. State Work Done w ' Well Destruction ❑ Well Diameter - Sealing Material (top 501 T X AaAlf-bei3 Wells Depth 55` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADOITION I I DESTRUCTION l 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line C SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L1 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 4 'rules and regulations of the San Joaquin Local Health Dr:trict. 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 shalt not employ any person in such manner as to become subject to wcrkman'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. I shall employ persons subject to workman's compensa- tion laws of California." The applici n ust tail f r all r .red inspections. Complete drawing on reverse side, l Signed x 1216aa #4931 Title:�rlRtr i�_Colac�lSf 11 GO t Date: _IL IIS1a1L FOR DEPARTMENT USE ONLY 5T 29. ' Application Accepted by _ Data q Area Pit or Grout Inspection by l=1 Date' C oFin+aall�Inspection by Date Additional Comments: Ty" 51+C ��V�^ �,r�� • `eft ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 1323-7104 ❑ 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¢ « INFO gQ CASH RECEIVED ECEIVED 8Y rDATE ;; PERMIT- NO. EHt3.241NEV. �5, TZj!q I��I - r �'II• {✓rV�/ EH 14-2e 1