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��}�I APPLICATION FOR PERMIT i.�'-° SAN JOAQUIN LOCALHEALTHDISTRICT W&� I 1601 E. 'HAZELTON AVE., STOCKTON, CA V Telephone 12091 A86=678'1 ,4� x, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED., „(Complete in.Triplicate) k - E1.�,VlROMENTAl �FALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo �rbe t! plication is made in compliance with San Joaquin County Ordinance No.549 for.sewage or No. 1862 for well/pump and the Rules�art� a�iam�s 8 an Joaquin Local Health District. ' Job Address �� 1ry City_ �-- Lat Size PM Owner's Name Q Address `- . C� Phone 209 UJae,Rr �ens�`p nLejl- �' Address 2-20 1� . 5 �VO Contractor License No 2Z3F '�.241 Phone TYPE OF WELL/PUMP: NEW WELL`g WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER IQ6cOv'%& r w�l1S't 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 !r ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation !0 int. Dia. of Well Casing ❑ Domestic/Private Gravel Pack 1 kTracy Type of Casing 9,y StAta y 0 PVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Sa 6041f-k8e) Type of Grout ❑ Irrigatlon --Approx. Depth ❑ Eastern .Surface Seal Installed by Repair Work Done ❑ Type of Pump N,'te H.P. State Work Done Well Destruction ❑ ' Well Diameter1i Sealing Material (top 50) ee Q McLt ^ Depth + +at Filler Material (Below 50') XC. cl L TYPE OF SEPT WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public ewer is available within 200 feet.) f' Installation will se . Residence— Commercial ther Number of living units: Number of bedrooms Character of soil to a depth f 3 feet: Water table depth SEPTIC TANK ❑ Typ Mfg Capacity No. Compart is PKG. TREATMENT PLT. ❑ ethod of � posal Distance t ear Well Foundation Property L LEACHING LINE ❑ No. & Len of es Total length/size FILTER BED ❑ Distanc to nearest: Well foundation Propert ine SEEPAGE PITS ❑ D th Sr Number SUMPS ❑ istance to nearest: Well Foundation Property Line 1 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 agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not l employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thi§permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X' /L• ZGGt/J Title: �v O'f Date: FOR DEPARTMENT USE ONLY c/� Application Accepted by �� Date Area Pit or Grout Inspection by Date Final Inspection by Date rG- Additional Comments: b : s ri�a c .�s s. s-�-ms or se, T l ees cv ,n ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Monte 823-7104. ❑ Tracy Sar S D tl_ C Jm [,t1 S Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, S C 95201iP� FEE AMOUNT DUE AMOUNT REMITTEDC SH RECEIVED BY'" DATE PERMIT'NO. INFO + EH 13-24/REV.I/r;51 C5,o EH 1426 �