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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 theworkherein described.This application is made in compliance with San Joaquin Coun Ordi ance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District a i � ,'} �cJ /,3 f— oS o l 6 Job Address jE&-491 RVAD 14 H I PLO f 0L r RD City H !_.T Lot Size PM Owner's Name l*H7-2ti1 PACIFICieQF_LIOES Address5. C F_9.0A CA 00 Phone -V 7 Contractor Fe. EXPW,20rt101.? Address PO. a 10� I Sldo/License No: 2b555bA SL_tef Phone Salto TYPE OF WELL/PUMP: _ NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ f tONITO1211.ka WELLS 7-3 ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER >(S01L RM106-S #-4 DISTANCE TO NEAREST: SEPTIC TP,NVK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION; AGRICULTURE WELL, OTHER WELL PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ In ustrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation�N_ Dia. of Well Casing r T �s ai r,,' avec, 'Gravel Pack ❑ Tracy Type of Casing_-wC/ST. SMEL- Specifications f-1 PL f-1% ❑ Other �,{Delta Depth of Grout Seal F IFF }^� p - Type of Grout CEf1 IJ_r . I f Irrigation 15-20..Approx.Depth I l Eastern Surface Seal Installed by Q C, I-X PLO@A 71-10" Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction . ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION LI DESTRUCTION l I INo 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. TREATMENY PLT. ❑ .I Method of Disposal Distance to nearest: Well Foundation Property Line I rr� L LEACHING LINE ❑ No. & Length of lines Total length/size uJ FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I IDepth Size Number SUMPS Ll Distance to nearest: Wel! Foundation Property Line 'DISPOSAL PONDS`E] E] 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, am k rules and regulations of the San Joaquiri 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 nor ,lk employ any persoh in such manner as to'become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature j- J 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 oft fo us pectin . Complete drawing on reverse side �� '�✓�T The applicant us c I for all re uired i G J . yC�3 �7 Signed X Title: Date- ` Q FOR DEPARTMENT USE ONLY {/ ! Application Accepted by .DatZ5)A f/ Area Pit o Grou Inspection by Date Final Inspection by Date rtional Comments: Cr1? fdl.,Oev tk 466-6781 ❑ Lodi 369-3621 ClManteca -7104 L1 Tracy 5 5 Applicant Return a!I copies to: Environmental Health Permit/Services 1 t Hazelton Ave., P. Box 2009, Stk., CA 95201 -7* p p!!= MITTED CK RECEIVED BY DATE PERMI7'NO.-W + EH 14-241REV.FixSj ��EH /yt 7 /5;` •w!� r'.� e'7.e Sim ..