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APPLICATION FOR PERMIT -\0\�USAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT P��<Ak�° � , 1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVED pPC�a�tiCN 1V Telephone (209) 466-6781 n E 0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMWT' l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thNtlrlc'Hdr�*§brl cl. 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. ` Job Address 3J- I/10-0!Z RDA-(7 City 4a 12, Lot Size PM tZ S&-Ts Ott-Co Li V A0 f _ C/o Bavc(woo.sGq� Y / / 1,1 zcc w) WE"� Owner's Name O 0", CUrtpApil Address M F'� WAST NK (—IV �To&(t rC Phone � Contra ctorl5k�At ltfajw, Addressft/ (-la 5(. 1 �� License No. 2-9'—Phone �O{/0 TYPE OF WELL/PUMP: NEW WELL MW-5 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 — tack Dia. of Well Casing 2"/NCS} ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ScJt 40 PVC Specifications ❑ Public Other RaVI'rOQ-04❑ Delta Depth of Grout Seal _ ^,3S FES Type of Grout ./-4VJ (� ❑ Irrigation —25 Approx. Depth ❑ Eastern Surface Seal Installed by 1700 7-4<701— 1— ,l Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation erve: Residence_ Commercial_ Other Number of living un) . Number of bedrooms Character of soil to a depth o eet: Water tabl pth SEPTIC TANK ❑ Type/Mfg Capacity N ompartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well dation Property Line LEACHING LINE ❑ No. & Length of lines Total le ize FILTER BED ❑ Distance to n Well Foundation Property L1n SEEPAGE PITS epth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL ONDS ❑ 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 that in the performance of the work for which this permit is issued, I shald�mplgyAger;q�s)syY �tAlv�grkrp�q g FQ p _C , tion laws of California." s IVV ff lvl ��1lUU It II``, LL 1 A6 f,' !Yi U I J I The applicant must call for all required inspections. Complete drawing on reverse side. ENVIRONr'TN11FAL HEALTH DIVISION SPECIAL Signed e—r°U / Title:' Date: / at_ 4µr4/ FOR DEPARTMENT USE ONLY Application Accepted by Date /2, Area Pit or Grout Inspection by Date Final Inspection by Date 42_,91i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO + EH 13-24(REV.1/N5) -R9 EH 14-26 s/