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The applicant <br />Signed X <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br />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 <br />Local Health District <br />Contractor PC , ExPLOlefkrIOV-) Address P.O. BO( 1101 ROSEVILLE 1:151c6/License No. 2io5.55(gAr-.4 -Phione ORR) n3-q733 <br />TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT 171 DESTRUCTION n No /..)t TorZikx, i,,.1 ELL!, 2_3 <br />PUMP INSTALLATION (A SYSTEM REPAIR 11 OTHER X...5viL <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />I I Industrial <br />1X. Domestic / Private <br />Public <br />I I Initiation <br />Repair Work Done <br />Well Destruction <br />TYPE OF WELL <br />LI Open Bottom <br />Gravel Pack <br />I Other <br />15-20 # Approx. Depth <br />C] Type of Pump <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Li Manteca Dia. of Well Excavation 434 Dia. of Well Casing a" <br /> <br />Ii Tracy Type of Casing NC ,/T. STEEL, Specifications <br />)6, Delta Depth of Grout Seal 2-5 FEET Type of Grout C.EI-1 /6Ek.fr <br />I I Eastern Surface Seal Installed by RC EA P1-012 A7101,-1 <br />H.P. State Work Done <br />Sealing Material (top 50') I Well Diameter <br />Depth <br /> <br />Filler Material (Below 50') <br /> <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence Commercial Other <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK Li Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE 1 No. & Length of lines Total length/size <br />FILTER BED I Distance to nearest: Well _ Foundation Property Line <br />SEEPAGE PITS I I Depth Size Number <br />'t\......, 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 <br />rules and regulations of the San Joaquin Local Health District. <br />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 <br />employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br />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- <br />tion laws of Califor.pi' <br />Job Address _C(2!2.K /20A0 3A HI P/0 HOLT 124) City HOLT Lot Size PM <br />I...A.1 CA 90017 Phone (z%)4771 Owner's Name ScakTHE.R..0 _Pr4CIFIC APE 1...10E5 Address PR:/?) 5. RGVEIZDA <br />SC C7 <br />SUMPS I I Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS <br /> Title: /P7t 7)"11)" 9-3D- 17 <br />for all re uired i Pectio . Complete drawing on reverse side. <br />Date: <br />Application Accepted by ZIA<P <br />Pit or Grout Inspection by Date <br />FOR DEPARTMENT USE ONLY <br />Datt0/07 <br />Final Inspection by Date <br />Area Vz3 <br />Si <br />d tional Comments: <br />tk 466-6781 D Lodi 369-3621 0 Manteca 823-7104 (1 Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1 1 Hazelton Ave., P. . Box 2009, Stk., CA 95201 <br />••• <br />EH 13-24 (REV. n 5) <br />EH 14.20 <br />FEE <br />INFO <br />- <br />AMOUNT DUE <br />r <br />AMOUNT REMITTED r&V RECEIVED BY DATE V PERMIT NO. <br />4.5G 6s- a 0-35°-c2- _Id li- qg yi-- /0q --s7 c7-3937