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3 APPLICATION FOR PERMIT S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) � Application ihereby 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 3 Local Health District. rS70LK70JV Job Address NLS IJIY/SKEY RD OppT/�APPfR Wcity UN/NC Lot Size PM Owner's Name PAC/F/C f7/9S�E1 fifARI[ CO Address RV, 'BOX 930 SWXTON 9.5-701 alone W711S39 Contractor IaENEM1 MY 7W7JON Address `AW S. 1141Y 470 License No. Phone S.? lJUS'f TYPE OF WELL/PUMP: NEW WELL M 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 Dia. of Well Casing i ❑ Domestic/Private ❑ Grave( Pack s ❑ Tracy Type of Casing_ ?Ir --- Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 97 fT. Type of Grout I�C � /2-0-!-Approx. Depth ❑ Eastern Surface Seal Installed by MQAe 6/9.5 � f1ECTR/l CU ep r�k &one« ❑ Type of Pump /1/d/VE H.P. State Work Done p Well Destruction ❑ Well Diameter Sealing Material (top 501 L�1/G-�3ETE IVP 97/7) i Depth Filler Material (Below 50')��i�E-BXEEIf ,BOTTLY+I 30F. " TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation wilt serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms {7� Character of soil to a depth of 3 feet: Water table depth Ia - SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line_ 6 _. 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 \! F 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. r 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 h±' 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." i The applicant must call for allrequired inspections. Complete drawing on reverse side. Signed X JOM/V /'YGYJ1EIN Title: fNll/I/EER-EST//WOR Date: 11-79-4&(P FOR DEPARTMENT USE ONLY Application Accepted by Date r2-1'—% Area 0 Pit or Grout Inspection by L11 Date Final Insc inn y Date Additional Comments: � Gra-4 9 1 ~ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT'NO. INFO + EH14-241REV.7/a5) EH 1426 C3 i