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I� I t a ' APPLICATIOI E IRPERM.IT SAN.JOAQILIWIOCAL EALTH DISTRICT. 1601 E.'HAZEL I ON AVE., STOCKTON, CA Y � � Telephone {209)'466=67$1' - p A L V EO PERMIT EXPIRES TNEAW ROM DATEISSUED FtEc� (Cornplete in TI iplicatell 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 i AL�4 made in compliance with San Joaquin County Ordinance No.549 for sewage or No, 1862 for well/pump and the Rules and Regulati�,Vui1Ay1& Local Health District. uN CJ �Smucls f �/� / � P�RN�1� i Job Address 50 k tZ !22 l kan 8, City L�Ud r Lot Size PM P O 00 Glut t dcr - cf e- lana- Owner's Name _C7 K t^� Q-n d y A4-5 C O. Address 15a D Phone C - Contractor PC a �on-1 7d)7, 4n C.Address DS�I/i/(� 0 9 (p� (9/G) Vi j— __� { icense No. 2�a 55.7(,a Phone_ ' 7 33 ' TYPE OF WELL/PUMP: ,2^NEW WELLS WELL REPLACEMENT ❑ DESTRUCTION ❑i_ �(pu� Q F/yu,� .. PUMP INSTALLATION (71 ,SYSTEM REPAIR ❑ OTHER ❑ of PrrC dosed Wo,-K- DISFANCE TO NEAREST:'SEPTIC TANK`S SEWER LINES DISPOSAL FLD. PROP. LINE Plor� / FOUNDATION �! - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r t /� �u ❑ Industrial ❑ Open bottom . ❑ Manteca Dia. of II Excavation t4 �-�— Dia. of Well Casing ' [-I Domestic/Private N 4 ravel Pack .❑ Tracy Type of &sing PVe � Specifications I`l Public IA Other ❑ Delta Dep h,o( rout Seal �-_5-5 I - O Type of Grout I Irrigation `Apt)roz:,Depth I I Eastern yySurrface'S al Installed,b�y Repair Work Done ❑ Type.of Pump\,,__,_o H.P. F State Work Done _ yWell Destruction ❑ Well of .2 Sealing Mate rr al l top 501 N 7"J.. Z»�DI�.a ae r(f J-, +� l)yI G'Nr�t7Y;h Oepth /^6 5't) 4]d Filler Material {Bo', 50'1 el �r112 « E OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I.I' ESTRUCTION�I'I (No septic system permitted it public sewer is �A' f available within 200 feet.) Installation II serve: Residence _ Commercial Other Number of living Number of bedrooms Character of soil to a depth feel: t /' Water table depth SEPTIC TANK ❑ Type/M g C parity No. Compartments PKIG. TREATMENT PLT. ❑ Method of Disposal. Distance to nearest: Well Foundation Property Line LEACHING LINE 1-i No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Found tion Property Line i SEEPAGE PITS I I Depth Size Number I SUMPS Ll Distance to nearest: Well Found tion Property Line DISPOSAL PONDS CI I hereby certify that I have prepared this application and that the work will be doe 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 I employ any person in such manner as to become subject to workman's compensa ion laws of California."Contractor's firing 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 Calif ia." The applicant uc/allll for all uire spa ons. Complete drawing on reverse side. p Signed X Title- Date: //J//t tl�, FORDEPARTMENT USE ONLY X u Application Accepted by 62 Jb-wt k C""^s Date �° i� y� Area Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: i i ❑ 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 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT'NO. 1 lam-