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r APPLICATION FOR PERMIT - o. WTV— 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) w =tet 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 hSaJoaquin C-0ontv.Ordinance No:549 for sewag N 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distr tisk Job Address D e ert s be p oT ► I2.FLG City 7-7)cref Lot Size PM ` Owner's Name N a e hippQ r--� Address '771ficv Phone O - S (.01 Contractor W �C a Mfav ✓Address 20 At CctdT St License No. � - a� Phone�9/ �olu�- TYPE OF WELL/PUMP: NEW WELL 15ir- WELL REPLACEMENT ❑ -. DESTRUCTION ❑ C\ PUMP INSTALLATION LIJSYSTEM REPAIR ❑ OTHER Alnan?7-09111G Oel� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /0 /uc& Dia. of Well Casing ❑ Domestic/Private Gravel Pack .jiTracy Type of Casing N 5Aecl 90 Al C- Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _54 t-Type of Grout k ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump No PV VA H.P. State Work Done Well Destruction Cl Well Diameter 'Lift Sealing Material (top 50') 8 Depth See- AHO-c h m 8or Filler Material (Below 501 C e r' Q d c r✓I r°nEb1 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet I f Installation will serve: esidence Commercial_ Zr Number of living units: Number of bedrooms Character of sail to a depth o feet: Water table depth SEPTIC TANK El e/ fa Capacity No. Compartments PKG. TREATMENT PLT. ❑ ethod of Disposal Distance to aest: Well Foundation /Pr rty Line LEACHING LINE ❑ No. &� ngth of es Total length/si FILTER BED ❑ Dist Tice to nearest: Well Foundation� Property L' e SEEPAGE PITS ❑ Depth ze Number f SUMPS �` Distance to nearest: We Foun ion_ 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. 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 California." The applica t must II for all require �insp aio Complete drawing on reverse side. Signed X Title: ogo Q 17 t Date: FOR DEPARTMENT US ONLY Application Accepted by r Date / Area_ C�nw Pit or Grout In bc,tion by L ate Final Inspection by Date Y zy A ditional Gommer4:CB D G T�1 a f� I`ZArT,a y.J 1 1�" i�C�°r' (�1r�o.� �.¢ i e!;%4 IS 5tk 466-6781 C3 Lodi 3�- 1 Manteca -7104 racy 835- ° NU VA�1C.z� Cr F Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 1 P_4 .Z..F N FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO- INFO CASH + EH 13241REV.1lB51 \s J r l 7'9 EH 14-36 ✓ t CILC al '36 , 03 I>J/1V o BIZ- �� `AVYEK /lei �/✓. ! f vn� i