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APPLICATION FOR PERMIT r. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F I-Ip7c� -nnl e\/F crnrKTnN CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appicaon isall the work cation is madle nticompliance withdSano the Sn Joaquin LocaJoaquin County Ordinalnce Nto.549 for sewagHealh District for a e or permit 1862 forcwell/dpump end the Rules and hereinR gulations of he Sant Joaquin Local Health District- L� Job Address WA i�llN,045 $111-• City Slockfei Lot`Size PM (d0 rJ Cz H r'Fl PiY �l•S./k Address 12-00 51ti l .H SiQ Ei 4%041311 L3 Phone�1' 65 6-77 55 Owners Nam KPILHAIIB Contractor 1676 RISCON ROAD Address License No. y 3 9'O Phone 68 6 rrlr� nen q�gb18 I TYPE—OF NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Sn^_n �(� `Ve f/C R /T ft lO PUMP INSTALLATION ❑ SYSTEM_ PAIR ❑ OTHER (� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z 5 T-A DISPOSAL FLO. PROP. LINErj� PITS/SUMPS FOUNDATION �- AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O. LS t M Dia. of Well Casing r N - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I 9 ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing t/C� Specifications Sla{-• C-CL= -,/ r GBi'I EA/] l ❑ Public ❑Other ❑ Delta Depth of Grout Seal l Type of Grout- IXC NICD)iOBI .C,�'�.pproz. Depth 'f4 Eastern Surface Seal Installed by VV •LI I#4Cr Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic systemithin rmi ted it public sewer is avaeet Installation will serve: Residence— Commercial_ Other I 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. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 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 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-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 m t all for all of spections. Complete drawing on r rse side. Signed X Title: K Date: FOR DEPARTMENT USE ONLY J ,,i-,-?� Date f 9 u Area jI Application Accepted by '• q �,ee .��1v/ C' l R/ Pit or Grout Inspection by � /'�' Date f Z Q / Final Inspection by 'r�\ F Date �� Additional Comments: CRC�� AA .e ❑ Stk 466-6781 ❑ Lodi�,369-3621 ❑ Manteca -7104 ❑ Tracy 83516385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED eY DATE PERMITNO. INFO . EH W4(REV.1,1x5) �� -, coC� T E /S ` EH 1428