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APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I 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 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— 1 Job Address City' `a v��C Lot Size�� PM L 1 pp i oh o 1! � Address sa7n. as J a6a1�P Phone TZ3- _4 /� Owner's Name �"1/ X2.5 � Contractor ACOt 1 �Q Address/ �• 6, � �, NOC�71X'L � License No-W623 Phoneg 3- /� TYPE OF WELL/PUMP: NEW WELLW WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ElOTHER ❑ a DISTANCE TO NEAREST SEPTIC TANK/00 `Yt, SEWER LINES leo i- DISPOSAL FLD.Z,06�t PROP. LINE 10 FOUNDATIONd/ '+ AGRICULTURE WELL OTHER WELI/OD'Y-- PITS/SUMPS f p� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 34 Manteca Dia. of Well Excavation f/ Dia. of Well Casing 151 Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications CA-14y- /90 �tl~ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout mF'y �! . ❑ Irrigation /0..a- Approz. Depth ❑ Eastern: Surface Seal Installed byelo Repair Work Done ❑ Type of Pump 5--L;b M.P. State Work Done E Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth fi Filler Material (Below 501 1 TYP SEPTIC WORK: NEW INSTALLATION,V REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: ce Commercial_ Other Number of living units: �_ Num_ edroorn Character of soil to a depth of 3 feet Water table depth SEPTIC TANK IP Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well 1100 Foundation Property Line I - LEACHING LINE ® No. & Length of lines Total length/size Va FILTER SED ❑ Distancetonearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth I 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 t rformance 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 c I r s ctions. Complete drawing on reverse side. # Signed Title: Date: + I z FOR DEPARTMENT USE ONLY s § r Application Accepted by t1� Date Z- Area /Q I t ,- s Pit or Grout Inspection Date �f Final Inspection by ` Date Additional Comments: Qn--ok t EX-Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104' ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE i< AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.1/8 5) �CIS ,� CA4 I IRA 96cd,82 ^7-EH 14-26 25 ( V