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APPLICATION FOR PERMIT PA Y M E N I SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. FIAZELTON AVE., STOCKTON, CA JUN •, �;�;Ir, Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUERVIRONMENTAL HEAI_T1' (Complete in Triplicate) nrr�.hJTJSFrwir-Fc� Application is hereby made to the San Joaquin Local Health District (or a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549(or sowa(le or No. 1062 for well/pump and ilio Rules and Regulations of the San Joaquin Local Health District. )1 r Job Address 5 lqS v5 I city 'DIGi L%=4 Lot Size 06 11A Zed PM , NJ Owner's Name SAe,)1 ©r 64 Address �� &* 9()Z3 `40rcae Contractor Ca Address GrkktC t�fd �a � — License No. S��Phnne -6 �7Z7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION [D PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER J1 3 W%oht+VtIftyoj 6401k5 Pt' _ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES 3>' 4't DISPOSAL FLD._t� PROP. LINE LI�l- FOUNDATION ZAGRICULTURE WELL -h—ft— OTHER WELL_ PITS/SUMPS A* INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation _;n 1w ,.S Dia. of Well Casing yl . 0 Domeslicl Private Cl Gravel PackIwL'f l ❑ Tracy Type of Casing - T �_ S pec�ifications ('I Public Other ?hong►jfl Delia Depth of Grout Seal Type of Grout�a + _ `• I I Iniparian ^_ Approx. Depth I I Eastern Surface Seat InstalledRepair Work Work Done 0 Type of Pump —AA— H.P. State Work Done U Well DestruDestruction ❑ Well Diameter _1A4tieL4 Sealing Material (top 50') 1X MoAl4av W% Depth_ [ Q{' Filler Material (Below 501 TYPE OF SEPTIC WORK., NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo sopor, system palmittcd it public sewer rs available within 200 feat.) 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 Cl No. S Length of lines Total length/sire FILTER RED ❑ Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS I I Depth Sire _ Number SUMPS Ll Distance to nearest: Well . Foundation Property Line DISPOSAL PONDS ❑ 1 hereby cenily 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 cartitias 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 cani(y that in the performance of the work for which this permit is issued,I shall employ parsons subject to workman's compansa- tion laws of California." The applicant call for all r ired coons. Complete drawing on rev rse side. ` Signed X_ Title: C' t a',' e.f �f� Date: s-t ��Q FOR DEPARTMENT USE ONLY Application Accepted by Date 65ho Area Pit or Grout Inspection by Date Final inspection by Date Additional Comments: ❑ Sik 466.6781 ❑ Lodi 369-3621 O 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 FEE INFO AMOUNT DUE k176REMITTED CASH RECEIVED BY DATE PERMIT•N0. tH 1;. tRt1l.I,N13� ;S, o� ��. vD /6 &o