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r APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 j .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.WUfof swage r o.1862 for wall/pump and the Ryles and Regulations of the San Joaquin Local Health District. 1 /� �l�7� .L7 •�� Q Job Adt. dress / Fr-��C- �d- Cic� Lot Size ? p+C Owner's Name f✓ � Address 'c/� Phone lJ � S20 Z— Contractor ' f rQ4/• " Address License No. Phone 0 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ -SYSTEM•REPAIRFO ''.1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1' - _DISPOSAL FLO. PROP. LINE — I FOUNDATION AGRICULTUREWELL (OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELLPROBIfiMAREA t(CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom O!Maritecii Y iDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trauy (Type of! —� Specifications O Public L3Other ❑ Delta (Depth of Grout Seal I Type of Grout 1 [I — IrrigationApprox. Depth 13 Eastern Surface Seal Installed by) Repair Work Done ❑ Type of Pump H.P.. I ( State Work Done i r I t Well Destruction ❑ Well Diameter Sealing Material (t6 60.1 Depth Filler MatEdal'(Belgw W') "J 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ )DESTRUCTION ❑ (No septic system permitted R public:sevrer is .� ✓/ available within 200 feet.l •i _ Installation will serve: Residence_ Commercial_ Other Number of living units:_ Number of bedrooms Character of soil to a depth//of 3 feet: E }`• ' �; Water table depth Q ( SEPTIC TANK 7JY1ype/Mfg apacity ` OO No. comparonents Q PKG. TREATMENT PLT.❑ 1 S. Method of Disposal _ Distance to nearest__ ) ell FoundafioD ' Pioperty Lin. LEACHING LINE ! (lNo. A Length of lines�'qct✓/�hC1 —:+/lJt'trf+`�fdTal length/size �,_, FILTER RED ❑ - Distance to neares: e oundatmn t Property Line SEEPAGE PITS ❑ Depth Size urNbgr —� SUMPS ❑ Distance to nearest: Well_ Foundation {Property Line — DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordan 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 Porto rmenae.of the work for which this permit is issudd, I shall not employ any person in such manner as to become,subject to workman's compensation laws of�ff imia "Comreetor's hiring or sub�ontrecting signature ` I certifies the folowin :"I certify that in the performance.ofaMwork-fonwhich-this parmit-is-Iss'UA,I shall employ-personsaublect.te.workmenis comperga- ` tion laws of 0 The applicant u c or u I ct Complete draw✓rg on r rse side Signed '` =�Ttle: Date; _ 1. + t� - > "FOR DEPAAI!MENT USEONLY Application Aeceptedby - •��' Date Area.— P160 Grout Inspection by y 1^ Date / � � Final Inspection by 11 � `/ Data 1 iR's .w:. i o I o��loK' evlipfl �G4 t ' I WS;4/moi ti�/Y+f Additional Corumen —� ( O Stk 4866781 L] Lodi 3�-3821 I ❑ Manteca 873-7104 I❑Tracy t 836- I LOB[ Applicant- Rotor hit copies Lb: Errv,�ronmerrtal�+salth P •/Services 1801 E. Hazelton Ave.,,P.O. Box 2(105,.Stk., CA 95101 -�a>wr /8'�19Sti: oTe N .' //� 4/9frr , j F 1 ! :FEEL INFO 'AMOUNT DUE t (AMOUNT RE ITTED CASH RECEIVED By IOATE PERM1VN0�• �f } I ) ( ♦EH 13-311REV.teem } � 1 f`•t/ � I I FH 1426