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APPLICATION FOR PERMIT SAN JOAqU!N .LOCAL HEALTH DISTRICT 1601 E. H' ZEL ON' VE::, STOCKTOi , CA tt Telephone (209) 466-6781 E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ow, (Complete in Triplicate) J U L Q 9 I,P9, �}II ��A+��..Ap��},�t. f��ion is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installvyO� IyI �Y'i'7( Qf� aquin made in compliance with San Joaquin CountyOrdinance No.549 for sewage or Na. 1862 for well/pump and the Rulpsla9/�NgR�IIL r1 Jo Local Health District.- Job �l( West " L-�,ne_ _ City!'t'Dc.n 4%n CA Lot Size PM Job Address �� Bu�1a�t � e17a35 � II -- L -t-�� L.P. $ L 01; 5�73�-&-99 � �,� Fr� Y1 bda .14K..• Address IWO KOC ` W��I— Phone Owner's Name L ,,.�{. 5l �G& CS-+ W r?QLD �1f ` IMA Address��"S& � """ License Ivo. phone Contractor t TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIONOTHER Y`�pRIJ,,,,rt PUMP INSTALLATION ❑ SYSTEM REPAIR F-1 `v DISTANCE TO NEAREST: SEPTIC TANK x SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION 30 fe`+ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Jt { ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 -tn Ria. of Well Casing I' o.,;Wr T e of Casin rVC Specifications I C (0❑ Domestic/Private Gravel Pack ❑ Tracy yp g - Type of Grout I'l Public F1 Other Cl Delta Depth of Grout Seal YP i. I I Irrigation /-Approx. Depth t l Eastern Surface Seal Installed by SC 't'� - , o"°` G' Repair Work Done ❑ Type of Pump pt�r H.P. State Work Done � Well Destruction Well Diameter Sealing Material {top 501 Depth 50 few — Filler Material ieelow 501 TYPE Of SEPTIC WORK: NEW INSTALLATION I ) REPAIRIADDITION I 1 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 tCapacity No. Compartments SEPTIC TANK ❑ Type/Mfg k PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE [77 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl 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 Dilarict. 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 l 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 applic ust call f II re'wired inspections. Complete drawing on reverse side. I Signed X Title: �*''GeoID IST �• Date: 5 R6 es M K FO RT SE O N LY Date �Ar i Application Accepted by 'f Pit or Grout Inspection b Date f �® Final Inspection by Date r�~ Additional Comments: L] Stk X466-6781� ❑ Lodi 369-3621 ❑ Manteca 823-7104 CI Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO (REV.1111 sl 14 26