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� 130 fZrNG-s Amo m a,v ,n�2I.v� APPLICATION FOR PERMIT �» SAN JOAQUIN LOCAL HEALTH DISTRICT u-- 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 11� Tt City U e e e L�P o cy f C L Lot Size PM Job Address `- Owner's Name Address 26 90 AQ Phone �2 0 z 9 S wl�r& 0611eLopko Nr 72-0 A/. £AsT S1 -DL4—D 2P3-326 CQi�� -ma y Contractor e Address '�1a38 ! o+sLicense No. °l�ay-�2 y _Phone r1 6s9"Oyo TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ SOIL 03vRlNGS PUMP INSTALLATION ❑ SYSTEM REPAIR C1f OTHER YLtWOAIM9/NCr Wt/[j DISTANCE TO NEAREST: SEPTIC TANK SEWEJ�'LINES } DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /O Dia. of Well Casing it Domestic/Private Gravel Pack racy Type of Casing y 5C/f iF0 r11/G Specifications 13 ' T ..__ ` ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Site– A-#Ar-Lime et Type of GroutIQn Ne ❑ Irrigation -.--Approx. Depth Ll Eastern Surface Seal Installed by ¢ Repair Work Done ❑ Type of Pump _� H.P. State.Work Done / Well Destruction ❑ Well Diameter Sealing Material (top 50') �� i✓� e s Depth S Pt Ad!ar�tv�lt+�1 Filler Material_(Below 50'} ° e ° TYPE OF SEPTIC WO NEW INSTALLATION ❑ EPAIR/ADDITION ❑ V7abt ic system permitted if public sewer is within 2 feet.) Installation will serve: idence— Com rcial_ Other. Number of living units: Number of edrooms tCharacter of soil to a depth 3 feet: er table deptlSEPTIC TANK ❑ Ty /Mf C . Compartments PKG. TREATMENT PLT. ❑ �' thod of Disposal Di nc to nearest: Well FoundaLine LEACHING LINE ❑ No. & Leng of lines Dial lengthls e FILTER BED Distance to n rest: Well Foundation Property e i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Fou ation Property Line DISPOSAL PONDS ❑ I 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 ernploy 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 California." r The applic t mus call for all required i ions. Complete drawing on reverse side. I'dooDWAn _Ct4loz p Signed Title: ,1"6 ge, 0!5/ Date: 2a FOR DEPARTMENT USE ONLY Application Accepted by Yv Date Area Pit or Glou io Inspec n by Date Final In n by Date Add'Itional Comments. , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 Applicant- Return all copies to: Env'onmental Health Permit/Se Ices 1601 E.,Hazelton Ave., P.O. Box 2008, S ., CA 9 1 � 27 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED 8Y DATE L'PERMITA'NO.eASR INFOEH 1324 IREV.1/e b1 � ' EH 14-26 �-