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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 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 isrsll the wort herein described. TMs application is made in compliance with San Joaquin County Ordinance No.509 for sewage or No. 1862 for well/pur std the Rule, end Regulations of the San Joaquin Local Health District. D Job Address r,.4I/Yr1 I it ` City// Tr, L Lot Size�,�/�j_ PM Owner's Name //�1 /' L Address S /0 Son-411 1(^t tL If/U Phoney. O 3 - �2-O Contractor SY' /'4t r^II< Address36o°/ rr 7' Lv a °License Na.aS 9�Z 7 Phone�k[T - )2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERAV cu,,te,.,Vlf l/ DISTANCE TO NEAREST: SEPTIC TANK 1114 SEWER LINES DISPOSAL FLD.//� PROP. LINE FOUNDATION 3,.032 AGRICULTURE VALL ArnlL OTHER WELLaSz PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing 2 ❑ Domestic/Private X Gravel Pack W Tracy Type of Casing PVC Specifications 1 Ul Public ❑ Other ' 1-1DeltaDepth of Grout Seal ,� ype of Grout�tWt"�L _ I I Irrigation lk�_Approx. Depth��JJJ I I Eastern Surfac Seal Installed by L�Se Yacr� G _ Repair Work Done LJ Type of Pump H.P. /l/� Q State Work Done_ 1 Well Destruction ❑ Well Diameter �r Sealing Material (top 50') /y r/��r SPa/�7 eG/'C 'Z( / Depth �L./ Filler Material (Below 509 rr Lyashi d✓e r rX1c-K be�n�n 14_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 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 Foundation Property Line LEACHING LINE ❑ No. B Length of lines Total length/size FILTER BED ❑ 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 ❑ 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 s ch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follow' g: 'I certify t 1 the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif rn .' The applicant at II f all inspections. Complete drawing on reversasMe. Signed Title: Date: 01_55 1� ��s.rlf FOR DEPARTMENT USE ONLY tl VApplication Accepted by 0,t? Date 1I(��Ff Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return ell copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Lt,+ iln�e�by r 1� rr 1� (` 1 (l OIF fe ? o q WJ..k S. ^&' Y cjr1 L.Xc.e,.jtd c-"iv-. C v- rtpr... cl - INFO AMOUNT DUE I AMOUNT REMITTED K H RECEIVED eV DATE PERM17 N0, ♦ EH I324IREV.1/e5r EH N-29 O.Q O �./`. Niii s ap\5 V