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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Z. 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1Complete 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 Rules and Regulations of the San Joaquin Local Health District. FW&W Job Address SLS (9t977#1V,S RD /75'Z/O B ILAIT AD City 4/N/IVC _ _ Lot Size PM Owner's Name FOj6 e AWS 7ffjf Address PD BOX '730 SM I'tT 95.701 Phone M-15.3? Contractor GfNEKfI (TAddress MDMA E. 941Y 470 License No. Phone 823 -10,991 TYPE OF WELL/PUMP: NEW WELL CK WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 A9 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 21 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 97 FT, Type of Grout X❑X Irrigation � /o�pprox. Depth ❑ Eastern Surface Seal Installed by PSC FY ZZe7R/C 610 Repair Work &Ke' ❑ Type of Pump NO/VE H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 KZWRETfTDP 87 FT. Depth Filler Material (Below 501 AOX'f-BRffZZ (BOTTD/'7 .3l FT. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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. & 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 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 must call for all required inspections Complete drawing on reverse side. Signed X T41/IV AVAURAI0Title: 'rN,&1NZZiR-E�,Sl//YP9llJ'?_� Date: FOR DEPARTMENT USE ONLY r� Application Accepted by ate Area � Pit or Grout inspection by - Date rnal Ins coonQy '"ilbara Additional Comments: �� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. + EH1241REV.t/a5} EH 14,26 Od