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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTOWAVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) :I 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.649 for sewage or No. 18M for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 91 116 Thd»tnn gnarl City St0r_kton Lot Sizal 40 r x 1 h 0 PM Owner's Name Srlithland Cern_ Address5R2O Strin�er1dgt- Mall Rd_PIe 2711 Contractor's Name Grnilndwater Tech_ License No. 4 3 4'143 Phone — TYPE OF WELL/PUMP: NEW WELL IB WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 50 SEWER LINES 2 DISPOSAL FLD. PROP. LINE l Ctft . FOUNDATION 15ft. AGRICULTURE WELL 200ftOTHER WELL_3DJJft.PITS/SUMPS -2— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --.� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin 2 in 7 Domestic/Private Grave! Pack ❑ Tracy Type of Casing PVC Specifications •82 0 in. 4 ❑ Public ❑ Other ❑ Delta Depth of Grout Seall0 f t.min, Type of Grout Cement r ❑ Irrigation 40rox. Depth ❑ Eastern Surface Seal Installed by Sierra Pacific Drilling —JI Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top.50') Depth Filler Material (Below 50') 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 ❑ 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. i 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."Contractoes 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 must call for all required inspections. C plate drawing on reverse'side. Signed X Title: ProjeL GeologistDate: _=5-21--RF ENT USE ONLY Application Accepted b22SWData S A Pit or Grout Ina b Date 'nal Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835,&M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. �.84 t�z.(REV.10/10) CFO �p/S f(��f S'23-p{o �p�a�► EH 147E