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The applicant Signed X 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) 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 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 Contractor PC , ExPLOlefkrIOV-) Address P.O. BO( 1101 ROSEVILLE 1:151c6/License No. 2io5.55(gAr-.4 -Phione ORR) n3-q733 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT 171 DESTRUCTION n No /..)t TorZikx, i,,.1 ELL!, 2_3 PUMP INSTALLATION (A SYSTEM REPAIR 11 OTHER X...5viL DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I I Industrial 1X. Domestic / Private Public I I Initiation Repair Work Done Well Destruction TYPE OF WELL LI Open Bottom Gravel Pack I Other 15-20 # Approx. Depth C] Type of Pump PROBLEM AREA CONSTRUCTION SPECIFICATIONS Li Manteca Dia. of Well Excavation 434 Dia. of Well Casing a" Ii Tracy Type of Casing NC ,/T. STEEL, Specifications )6, Delta Depth of Grout Seal 2-5 FEET Type of Grout C.EI-1 /6Ek.fr I I Eastern Surface Seal Installed by RC EA P1-012 A7101,-1 H.P. State Work Done Sealing Material (top 50') I Well Diameter Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 Li Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 1 No. & Length of lines Total length/size FILTER BED I Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I I Depth Size Number '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 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." Contractor's 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 Califor.pi' Job Address _C(2!2.K /20A0 3A HI P/0 HOLT 124) City HOLT Lot Size PM I...A.1 CA 90017 Phone (z%)4771 Owner's Name ScakTHE.R..0 _Pr4CIFIC APE 1...10E5 Address PR:/?) 5. RGVEIZDA SC C7 SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Title: /P7t 7)"11)" 9-3D- 17 for all re uired i Pectio . Complete drawing on reverse side. Date: Application Accepted by ZIAPit or Grout Inspection by Date FOR DEPARTMENT USE ONLY Datt0/07 Final Inspection by Date Area Vz3 Si d tional Comments: tk 466-6781 D Lodi 369-3621 0 Manteca 823-7104 (1 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1 1 Hazelton Ave., P. . Box 2009, Stk., CA 95201 ••• EH 13-24 (REV. n 5) EH 14.20 FEE INFO - AMOUNT DUE r AMOUNT REMITTED r&V RECEIVED BY DATE V PERMIT NO. 4.5G 6s- a 0-35°-c2- _Id li- qg yi-- /0q --s7 c7-3937