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'+ ' • APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 6C y 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. 1662 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District.' / /J �,, � Job Address ?-5- FSS//II✓/746/ed Ale oh / City Lot Size _ PM Owner's Name (�D.QC'fi/A fAe/fie 610 ppAddress S/J/Y1gq0 AS 1,76045 Phone 2dq- d- Z/f- Contractor .B,PdNn/d eA/Dn/�// Address601&6d /✓A�,1o/lL'.AWAI� 6A License No. Phone K - J -9d/ TYPE OF WELL/PUMP: NEW WELL V 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 US��/EeQ� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11IRduemal r✓e9y0, /7 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing til ❑ Domestic/Private X Gravel Pack Dd Tracy Type of Casing Pde Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal /d.f D/ Type of Grout 44/10,7; ❑ Irrigation &�Approx. Depth El Eastern Surface Seal Installed by / iA 6 Q)e d ltd Repair Work Done ❑ Type of Pump ly AWr H.P. State/Work Done �.y Well Destruction ❑ Well Diameter N Sealing Material (top 50'1 �4•f /a Q 7 &nod//"ZP Depth__ Filler Material (Below 509 /6'Q -,eld 'tt 3fAAQ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted If public sewer 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 ❑ 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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." 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." Theapplicant must call for all 'reequi'redt in/s,)p��ctti�ns. Complete drawing on reverse side. Signed X K �/ r^-c-cv"� Title: /' - Date: 1,16�A f FOR , Z- FOR DEPARTMENT USE ONLY Application Accepted by / C, Date �� .� Area �7 wwlew lam 0 ALL! / Pit or Grout Inspection by p�� / Date Final Inspection by / Date Additional Comments: //.Qy11//1 C7 Sug��nf2ne>a,P .2I/o�17/Q/del d Arsdo 3>OC't'>d/✓ 2d9.99f1- /?�lt� ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 1b7A IREV.1/8 51 EH 141e