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W Mac}l �A/�ar� • APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT m_ (1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 CU 'n' 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 Ryles and Regulations of the San Joaquin Local Health District. 1 ,, / '5Z I Job Address 16-0 /V /NCL/1//Z /fit/', City '5Zel-/L 1v Lot Size -- // PM Owner's Name-f'z�r^CCL/ iClsG/G l�•Address /57 A . 51 1E,j 3t/! Phone Contractor ri-i /ZS 'COs � Address1/�/✓fnL1� - License No._723/D Phone TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION g SYSTEM REPAIR ❑ OTHER Pr /11C'V 17-,"L Ct�LLS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS 1nd"ft^af.41QA✓17E Q 5 Open Bottom E Manteca Dia. of Well Excavation Dia. of Well Casing T ❑ Domestic/Private AGravel Pack ❑ Tracy Type of Casing ✓C- � Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .3—'i�- T v r / Type of Grout ❑ Irrigation !�z Tl�y YY iLr 9 �C._Approx. Depth ❑ Eastern Surface Seal Installed by� Repair Work Done ❑ Type of Pump 5✓ /H. H P V3 y State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 G%a-L'24 r Depth Filler Material (Below 50') 4D7{;/16Y 154 p TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1i15tallation will serve: Residence— Commercial— Other available within 2D0 feet.) Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 1�pe/Mfg CapacityNo. 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: -Well Foundation Property Line i 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 t in the performance of the work for which this permit is issued,I shall employ pentons subject to workman's compensa- tion laws of Californ' .' - The applicant or II squired ins�7cttiions. Complete drawing on reverse side. Signed 'f '/� Title: ziryolzez ek:,lI Date: �?2- 4l4y FOR DEPARTMENT USE ONLY Application Accepted by Date At Pit or Grout Inspection by �c^' Dat `- X F' al Inspect!on by Date Additional Comments: W _ ❑ Stk 466-6781 - ❑ Lodi 3633621 ❑ Manteca 823-7104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J FEE AMOUNT DUE AMOUNT REMITTED INf-0 _(]� v CK H RECEIVED BY DATE PERMIT NO. ♦ EH 13-24(REV.1/e 5) TSYI% �a 0V 11�t 7 8S-0-y2 EH 1C25 PS- 5'8 !✓ t ..