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APPLICATION FOR PERMIT r - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA T Telephone (209) 466-6781 1?A� 1vD PERMIT EXPIRES TYEAR FROM DATE ISSUED R� iComplete 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulation Local Health District. JJ_ � Mt� �N pCVJ� i�ER�ltiC5 Job Address SOl� rc. /-00 e� City Coal` Lot Size PM a 0 op 1�1 a yt ec a_ d-c la, Owner's Name . Address Fti Q 3 Phone C 010 ContractorP,Y-aA&7, LnC,Address DSE YI I�C, 9J�(p 7 _ License No. Z&555Cv�Phone_ — 7 53� TYPE OF WELL/PUMP: 2 NEW WELL6,1K, WELL REPLACEMENT ❑ DESTRUCTION ❑ ptAoG,e cc{�grt PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ e�cj°sed taFa - plc n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing £ 114 ` ❑ Domestic/Private �iravel Pack ❑ Tracy Type of Casing P V e r ` Specifications lZU4 t- 11 Public C1 Other ❑ Delta Depth of Grout Seal ?-SS 1—�O Type of Grout� L4- I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter a if Sealing Material (top 50'1 N t! n�1 Xmg-nd-onrt Depth 1-l05% 1 -�9d r Filler Material lBelow 50'1 A10- Q0/4D --- E OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation it serve: Residence_ Commercial_ Other Number of living Number of bedrooms Character of soil to a depth feet: Water table depth SEPTIC TANK ❑ Type/M g 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 i I 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 Calif ia." The applicant u `call foralluife spe ons. Complete drawing on reverse side. Signed X Title: r�'P�!C f t"-vZ Date: `� r 4 FOR DEPARTMENT USE ONLY Application Accepted by r '✓" r,k C..AIS Date I:. +( rr Area j Pit Grout I pection by Date Final Inspection by „T Date `zJ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 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 sC �tC 1a. �� e g ,.0,.x.11c� CL-�_:d sdll.z. FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'ND. INFOCASH + EH13-241REV. EH 14-28