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r • APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ENVIRONMENTAL HEALTH Telephone (209) 466-6781 PEPMIT SERVICE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) 3 OCT -5 PM 2: 13 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 7901 112C-A441`klr DCW City L Lot Size PM I P.O BoY 1??9 (.ftoo) 534- ?466 Owner's Name kegT%yg7 I'boc1S Address &wie e f CO -SOl17- 3•IDo Phone (ZOO S'35 ' 14L6 S�azk}o., Ca zo9 Contractor 5 ¢r.-' 1nv� C'r Address 25 4 te-} License No,5/22G X Phone TYPE OF WELL/PUMP: NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER �. MOrltrtc� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIngPOSQL FLO. PROP. LINE zC FOUNDATION 10/ AGRICULTURE WELL >50 OMR WELL °22 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R Dia, of Well Casing z ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing �S,y Specifications qq ate�j}' I f'1 Public Ll Other fl Delta Depth of Grout Seal Type of Grout vtt Ilfi a"pn- 7QLApprox. Depth I I Eastern Surface Seal Installed by - Repair Work„D%e ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter 7 Sealing Material (top 50'1 Alyi.� �eN'1¢n�' / gevt,x.: Depth 217 Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is ,dI a.! available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Mm�. - 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 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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."Contractors 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 applicanntt rimst call fo quired ' ctions. Complete drawing on reverse side.- I Signed X_1' Title: r0� 6�d 0 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date 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 LgMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT NO. }24(REV.11.sr r.ja