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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Z 'k 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 Z j! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CP 3 0'1 '--- (Complete in Triplicate) P,J Application is hereby made to the San Joaquin Local Health District for apermit to construct and/or install the work-� 6!ir�` 401 -T;�_,Application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No: 1662 for wellipump and the Rules add Regulations of tfte` at;Jbiquin. Local Health District. Job Address ------A!1�2 Vks� LxVerk'ov-d S+y-e,.-_+ City Lock Lot Size PM Lod CA Owner's Name Mar ex_kiM Address L-OckAl6d (�fe. D 0152_1+0 ' Phone C2 o 9)l 304.11 3(011 6,u�e CA Contract, All Timm L-,_(P1or0bQL(L Address 0330 Bt-em 91561ALicense No. 431 6 3 to Phonebql —'211'11 TYPE OF WELL/PUMP: NEW WELL Va—tP-r - WELL REPLACEMENT 0 DESTRUCTION'O PUMP INSTALLATION ATION 0 extiucho') SYSTEM REPAIR 0 OTHER'O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. :iPROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL-5--P+. -:IPfTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C3 Industrial C3 Open Bottom 0 Manteca Dia. of Well Excavation LQ Dia. of Well Casing 0 Domestic/Private Gravel Pack E3 Tracy Type of Casing fwc Specifications'irt"-� 7 Public n Other 171 Delta Depth of Grout Seal - 15 -Peet Type of Gmut�]J'5 ,. I Irrigation N_Appfox, Depth I I Eastern Surface Seal Installed by Repair Work Done ❑0 Type of Pump t4A H.P. State Work Done Well Destruction 0 Well Diameter41 Seating Material (top 501 \10wr E;K+MC ht-')k!�]Z Depth "32 Filler Material (Below 501 TYPE OF SEPTIC WORK-- NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sdwer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: — Number of bedrooms Character of soil to a depth of 3 feet: --Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of fines Total length/size— 'ILTER BED C3 Distance to nearest: Well Foundation— Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation— Property Line DISPOSAL PONDS 0 1i Jl I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sta't'e 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hi. permit is issued. I shalt not em so a ng signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall King or sub-contracti tion laws of California." ploy per ns subject to workman'scompensa- The applic m call for requir d inbpe tions. Complete drawing on reverse side. Ir Signed X Title: rtnu e01R.RAA4131 FOR DEPARTMENT USE ONLY Application Accepted by Date i Area Pit or Grout Inspection by Date Iq I Final Inspection by Oats 1 + Additional Comments: 0._P,2 0 Stk 466-6781 0 Lodi 369.3621 CI Manteca 1123-7164 0 Tracy 835-6385 Applicant - Return all Copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA' 95201 /1 ey 00 FEE AMOUNT DUE AMOUNT ftEmirrED CAS CEI E"Y INFO H DATE -.EH 13-24(REV.I/HsI EH 14-20 ap