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APPLICATION FOR PERMIT1 0 9 1�rw ' ws,i� gras SAS JOAQUIN LOCAL HEALTH DISTRICT J U L 5 140' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES TYEAR FROM DATE ISSUED PERMIT/SERVICES (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. I / Job Address GraafU Line Pot. Corra( j !OROW FOiCity t ref Lot Size PM Chevroyl �I�el1�C. Address '252S /� -Al,/0 C..NQSIe{r Phone Owner's Name n 1 C?K<r5 ;e CA 93308 �Y/ ? Contractor P• C. Xf'Orp�iO� Address (7 O V e 6" S'Frwe C 3 License No��,J6 Phone av 7g-347 3 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ A,� tt PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERk /VtoN;Tor DISTANCE TO NEAREST: SEPTIC TANK 0-120 SEWER LINES 7�A '—(RO' DISPOSAL FLD. PROP. LINE 25*" �b0� FOUNDATION AGRICULTURE WELL OTHER WELLa2'7V PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^ rf ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L ❑ Domestic/Private X Gravel Pack (Tracy Type of Casing PVL Specifications Cl Public Cl Other (1 Delta Depth of Grout Seal Type of Grout C2rn 2"t I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 CeMerl f °j ►1kf y ellets Depth 2 Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other_ (� �V (t1 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. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑- Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS I L. Depth Size Number SUMPS 0 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 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." The applicant rost call for all equired .nsspec ns. Complete drawing on r verse side. Signed X 1.� — Title: e G f Gea(� !S Date: FOR DEPARTMENT USE ONLY p q Application Accepted by .1 Date Ci ! Ar -30 / Pit or Grout Ins a / `/ 3`�J pection by Date Final Inspection by Date Additional Comments: 10 ❑ 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 AMyfOUNT DUE AMOUNT REMITTED CS�Hp -RJE�CC)EIVEED BY /DATEC� 1'71-17Sa-I PERMIT'NO. . EH }24(REV.t i x 5)1 EH 114-2.6 ,I t� ! �`^-'CT 1 l r/ -7