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ii " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T 0`Nj4AVE., STOCKTON, CA Telephone (209) 466-6781 I� PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED "1` ' I' (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 Ryles and Regulations of the San Joaquin Local Health District Y ' tom. '�''°` _ '`� 4 0J 10 • - 3 x Job Address 8&07 T1Z1K'4&UMI1V P ! City c. ICN Lot Size J 10 X 1.3 o' PM - -.Owner's Name Wells EAG a Siga Address /fir tltell De- -- Phone �Contractor 16RLEh S SQL's Address"P 8 9f4 License No.2SS!343___Phone fo(p',�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑,-, SYSTEM REPAIR ❑ OTHER ❑ OQ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS `. ,IINT-ENDED!USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ �ublic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i i ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by = Repair Work Done El Type of Pump _H:P. _._ State W Done Wel! Destruction ❑? Well Diameter ; Sealing Material atop 50') j Depth;E Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ■ DESTRUCTION 0 (No septic system permitted if public sewer is Q# available within 200 feet.l Installation will sere:` Residence_X_ Commercial_ Other->• - Number of living units:- is Number of bedrooms !�f ' Character of soil to a depth of 3 feet: IOW MY1 k Water table depth SEPTIC TANK 10 Ty /Mfg Capacity t2Ce-------- No.1 No. Compartment PKG. TREATMENT PLT:❑ Method of Disposal Distance to nearest: Well Foundation i O� Propdrty Line LEACHING LINE ❑ No: & Length,`of�linds --- otal'Iengw/"size FILTER BED ❑ Distance to nearest: Well Foundation EProperty,Laine , SEEPAGE PITS ❑ Depth Size Numfie�r""" 2 " SUMPS ❑ Distance to nearest: Well Foundation 0Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance wIth San Joaquin coon y.ordina'riEg state laws, and rules and regulations of the San Joaquin Ldcal Health District. f "Home owner or licensed agent's signature certifies the following: "I certify that in the performan e o the work for which this permit is issued;-i!shall not kempIoy any person in such mann!1-as to become subject to workman's compensation laws of California." Contractor's hiring or sub contractin�'signature , �certi ies the following:"I certify ithat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- jtion4 laws of California. r5 : f The applicant must call.for all required ins �ctions. Complete drawing on reverse-side.,K ;" KP .iSignedTitle: Date: .. ... k FOR DE IVT USE ONLY �Q L.11, i n ccepted by Date Ar ction by ` Date Final Inspection by Date Additional Cort#ents ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 L 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 CK 0 RECEIVED BY DATE PERMIT'NO. INFO CASH J/ (P / + EH 13-241REV.1/e 5) �'-�'S-QV - � _ I+'�•� as/ yL�7 EH 14.26 f