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APPLICATION].FQR PERMIT SAN JOAQUIN LOCAL .HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA' RECEIVED Telephone {209),.466-6781 `. JUN 1 6 1393 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED SAN 1OAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICE'S ENVIRONMEN d �Y fHi0ji00d4flbn Is Application is hereby made to the San..ioaquin Local Health District for a permit:to construct and/or install the work herein e made in compliance with San Joaquin County Ordinance No.549 for sewage`orNb. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. L.C� C ��' _rorrte LC, Job Address $s 1 E. L01b= AUI~r•]V E city L01CCE:_-7 Lot:Size PM ; Ir. /VI�TL�IL1zJ� LINCAL[J! a Phone Ownef's Name Address WN(_• Zti R► ?� Contractor Address r�D License too. _ Phone �36 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 SC).l(,-$oeltJG PUMP INSTALLATION 'SYSTENI REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial' 1a Open Bottom G Manteca Dia.`of 11 Excavation Dia. of Well Casing !^��h N CI .Domestic/ Private 1:3 Gravel Pack, E,Tracy Type of Casing � �' �� Specifications .*,�.. (1 Public �ther t:: Delta Depth of Grout Seal 4� Type of Grout ky_�"""' _ I I Irrigation dg>Approx. Depth 1 i Eastern Surface,Seal Installed by Repair Work Done L3Type of Pump H.P, State Work Done _ Well Destruction ❑ Well•Diameter Sealing Material (top SW Depth Filler Material RBel6w 501 If TYPE OF SEPTIC WORK: NEW INSTALLATION :i REPAIR;ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commerc:ai— Other = Number of living units: Number of bedrooms 'Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments is PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation ..Property Line f LEACHING LINE: ❑ No. & Length of lines Total length/siie FILTER BED ❑ Distance to nearest: Well Foundation - Property Line ti'Z E SEEPAGE PITS l I Depth Size. Number SUMPS 0 Distance to nearest: Well Foundation Property Line Ir 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. t 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 applicant mu for re rad i pections- Complete drawing on revetse side. �� Q ' Signed—W Title: + Date: t FOR DEPARTMENT USE ONLY Application Accepted by Data � � Pit or Grout Inspection by nal.Inspection by Data i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C: Manteca 823-7104 ❑ Tracy 835-6385. �Q•d0 J� Applicant - Return all copies to: Environmental Health Permit/Servides 1601 E. Hazelton Ave., P.O.Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H'RECEIVED BY DATE `S {PERMIT NO. .r.EH 13-24(REV.s i w 51 EH 14-28