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APPLICATION FOR PERMIT _j�"d1i, SAN JOAQUIN LOCAL HEALTH DISTRICT ir�,7 q 1601 E. HAZEL T ON AVE., STOCKTON, CA / Telephone,(209)466-6781 x; ,1,w.ti, # IPERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 4, (Complete in Triplicate) HEALTH u+.+, Application tion is he+eby maade to the San Joaquin Local Health District for a permit to construct and/or install the work araC+ scribed�T .a5a�'pP�ation is made compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and ulauons of the San Joaquin Local Health District. / /9 l r - 1' City STD !kraWL., Size PM } Job Address !` / +� / l/ '� y Owner's Name (�9 At �n�PDL'AT/o^L Address V / �S All C/4L. �Ll�� Phor�e7� Phone Contractor SP r pl 660400ATla,/Addresses �� "cense No Phone 8W 45 TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT LI DESTRUCTION ❑ F/ /L BOL'r'�iS PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 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 �j s2S � f– INTENDED of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications F1 Domestic/Private -❑ Gravel Pack ❑ Tracy Type of Casing OtherAOlL��n Delta Depth of Grout Seal Type of Grout��H�'��^� �� [`l Public - 1I irrigation r .Approxi Depth i I Eastern Surface Seal installed by t 'f ;"H P State Work Done / } T r {ID Repair Work Done ❑ Type of Pump 1 W„ 6G W 7�L`/Z fa2r1�+•�D ��r ok- Well Destruction ❑ Well Diamet Ir Sealing Material Itop i 4 Alldbjto../AfAl WTL Depth % as —' Filler Material (Below 501 E 7FF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION l 1 DESTRUCTION.I,1_ Mailable+w shire 200 feet.) 1t Public sewer is Installation will se ence J Commercial_ Other Number of living units: Number ms Water table depth j Character of soil to a depth of 3 feet:li No. Compartments SEPTIC TANK ❑ Type/Mfg city i Method of Disposal f PKG. TREATMENT PLT. ❑ G}- Distance to nearest: Well Foundation Line I Total length/size LEACHING LINE ❑ No. & Length of lines FILTER BED 1-1Distance to nearest: Well Foundation Property Line I SEEPAGE PITS C I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ill be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work w rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signaiure certifies the following: "1 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." Contractors hiring or subcontracting signature i certifies the following: "I certify that in!the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applicant mu;t II for I re red ins eons. Complete drawing on reverse side. S �� Signed X itle: f yv,e�� - L c3 r _ Date: T . FOR DEPARTMENT USE ONLY Date f 2 2- & Area Application Accepted by f Pit or Grout Inspection by /U � Date Final Inspection by Date I Additional Comments: l ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 835-6385 [ Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 O G RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED H INFO r EH 13-24 CR EV.1/N 51 r EH 14-26- ,"'