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SA JOAQUIN LOCAL HEALTH DISTRICT• 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CompleW 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 C n Ordinance No.549 for saurM N 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distrr--7 ¢0 ��`_ 6:1 Job Address De Eeo Si�_ be, Or `Ti2Cw..0 r/ City Z^UC' La Site PM Owner's Name Det ekt s e U p G, T " Address —Ft- CIp'f- Phone Contractor W MtW Address Sr License No. aF -326 Phone - i'i (� TYPE OF WELL/PUMP: NEW WELL bk WELL REPLACEMENT ❑ DESTRUCTION ❑ (� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER $jn orlt roll/Ni;- 0c 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 iurH Dia.of Well Casing ill 17� �. u ❑ Domestic/Private 'LGravel Pack Tracy Type of Casing H <hed ire h�VG Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Cee A&LA& Type of Grout " ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by r� Repair Work Done ❑ Type of Pump /J0 �1M'r{' H.P. _ —�_ State Work Done_ F Well Destruction ❑ Well Diameter 14" Sealing Material (top 501 Se ' 0 Depth See A9O_-_ mrnf Filler Material (Below 50'1 ';Pe O&Ac isae0t (� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet'l r` Installation will serve: esidence_ Commercial_ Cither � Number of living units: Number of bedrooms Character of soil to a depth o fee[: \ Water tattle depth SEPTIC TANK ❑ Type/ Ig Capacity_ No Compartments PKG. TREATMENT PLT. ❑ �. Method of Disposal f Distance to arrest Well Foundation Pr Line S \ LEACHING LINE ❑ No. & Length of ' as Total length/si FILTER BED ❑ Distance to nearest: Well Foundation Property L'ne �\ SEEPAGE PITS ❑/Depth Size Number I SUMPS 17 Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the walk 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 i shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiri or signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employe ' compensa- tion laws of California." ir Theapplicapt must yell for all required ins P uo : Complete drawing on reverse side. SignedX�,Gy�:CCL:�I r/ Title: d C' c:�' Date: / �i ,P z ARTMENT US ONLY Application 0 FOR DEPAccepted by ��r"�'^'��""' Date /r� O o Area CM Pit or Grout In ction by Date Final Inspection by Date l L a t o v }oto I z/kTt D IJ +V r fact PMa y �, �A (i i'�'s� Additional Comma s: Stk 466-6781 ❑ Lodi' 369- 1 Manteca 7104 racy r N(1_ t(7f)'I�G1'L- CJ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 1 0 R_41LL,f Ad FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 6Y DATE PERMIT N0. , INFO CASH (� EH1}34 IREV.ria 51 3Jj^ /�� (/ EH=6k. fl t c.-Al 136" 00 PAA- AA- o 14/L +--et lAGYF c G/�S �N. /� G7/v i✓ . ,