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APPLICATION FOR PERM17 �- SAN JOAQUIN LOCAL HEALTH DISTRICT :', 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-TM 46 " 3yk6 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 work4tpSairedespribed„fhw Application is for well/ um and the Rules and'Regulations olltlie3an Joaquin for sewage or No. 1862 o p p made in compliance with San Joaquin County Ordinance No.549 g Local Health District. 11 Job Address -7 b 5 Q 1D 0\r\5 7 \NA ny oG & City X� Lot Size PM Owner's Name-'SXLR \SQ ^t�rtc T Address -Vrcx t cc-A. F '� Phone Z09 'g32.- `143L lUoo �� Contractor u �°-��- \epna..kGrf• Address -� N • 'L License No-�D _Phone 9/6�66Z-L829 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERIS” 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 y tr ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation r0 inL Dia. of Well Casing ❑ Domestic/Private Gravel Pack ikTracy Type of Casing 4"sale d 110 QVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal -V-e a.Hau(•J Type of Grout W R//•vc.A.c� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump t H.P. State Work Done Well Destruction ❑ Well Diameter titr Sealing Material (top 501 Sf-Q A AOAt% r.n I- Depth 5<C ciyt z 1.• .t. Filler Material (Below 501 SCC- -Ak-c 1`^'tet'^")• TYPE OF SEPT WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public war is available within 200 fast.) Installation will se Residence_ Commercial_ cher Number of living units: Number of bedrooms Character of soil to a depth f 3 feet: Water table depth SEPTIC TANK ❑ T Mfg CapacityNo. Compart is PKG. TREATMENT PLT.❑ ethod of I Distance t a Well Foundation Property L LEACHING LINE ❑ No. & Len of as Total length/size FILTER BED ❑ Distant: to nearest: Well Foundation Props ine SEEPAGE PITS ❑ D th Si Number SUMPS ❑ ist to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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: "1 certify that in the performance of the work for which this permit is issued, 1 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,1 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,/�/� Lf- / • la-4 Title: Dare: �Z j!�Q41 9.-y, pts o- yI9/B S FOR DEPARTMENT USE ONLY Application Accepted by !y/ z A.� ...�^^� Date ` v t+ Area Pit or Grout Inspection byDate Final Inspection by Date Wo / Additional Comments: W 0 pgb'l'C- WL'nb, pf 1ya4t (AX�'�In5, �h/C- 5\ **" or .5cAxr //1�.5 wrin ❑ Stk 466-6701 ❑ Lodi 3821 ❑ Monte 823-7104 ❑ Tracy 5 45LY O OfO i r UJ, S r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S C 95201 FEE I AMOUNT DUE AMOUNT REMITTEDC SH RECEIVED By DATE PERMIT NO. INFO / ♦EH 1}2t IREV.trwsl 1,,� 0 �� --(1 r - EN 1L215 r i S-.\o fe'l l dLJrc / wj7 C for a inti yr insAe 113.