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ANNLIL.Httv�• �•, - . .. �/A J� JOAQUIN LOCAL HEALTH DISTRICO I'✓ 1601 E. HAZELTON AVE., STOCKTON, CA 1Telephone (209) 466-6781 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 patnd the work hare'^described. f th his✓SaJoaq kation• N 1882 for well/Pu mp and the Ruta and Regulatbns of the San Joaquin made in compliance with Joaquin CQLrn Ordinance No.54g fo��- Local Health Distr ,, .J [/ C 1f� (� 0 aC City TQ Lot Sim—�— PM E✓I s� Job Address 1' �T-- O f a, - Phone Owner's Name 1J L'T'ei� e D oT ) Address O GurT sr License No. a�3'2a" Phone 9 2- -- 1j Mtw ✓Addrdress ems — DESTRUCTION C3j. Contractor WENT REPLACEMENT ❑ NEW WELL IC OTHER )5 Ir o nI T°RUivG TYPE7YPE OF SYSTEM REPAIR ❑ PUMP INSTALLATION C3SYSTEM TLD. PROP. LINE — SEWER LINES PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing f W ❑ Open Bottom ❑ Manteca Dia. of Excavation f0 r' ff Specifications (J ❑ Type of Casin u< d k o h I G Industrial Spec H Gravel Pack �ZTfacy S!e /I•Nttc�wtn~Type of Grout �• ❑ Domestic/Private Depth of Grout Seal �— -- ❑ Delta ft' Ll Public ❑ Other Surface Seal Installed W lt`\ ❑ Irrigation � C)pprox. Depth Eastern State Work Done T of PUMP . P H.P. h Repair Work Done ElTypeMaterial (top 50'1 t Ufa ellf (' Well Destruction ❑ Wellell Diameter L410 Depth Sr 2 A rrach,yLe1r Filler Material (Below 50') available within 200 feetzl n\ TYPE OF SEPTIC WORK:ANEW ❑ REPAIR/ADDITION ❑ DESTRUCTION 11INo septic system permitted if public sewer rs SHherl_ Installation will serve: esidence— Commercial Number of living units: Number of bedrooms Water table depth Character of soil to a depth o feet: Capacity No�Compartments SEPTIC TANK ❑ Type/ fg JAethod of Disposal i PKG. TREATMENT PLT. ❑ / Foundation Pr arty Line Distance to safest: Well Tota length/si LEACHING LINE ❑ No. & length of es Foundation / Property L' e FILTER BED ElDist�ice to nearest: Well j i i' Number---------- �%Depth ze Property line SEEPAGE PITS Foundation _... SUMPS Distance to nearest: W state laws, and DISPOSAL PONDS San Joaquin county ordinances, � ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with rules and reI shall not gulations of the San Joaquin Local Health District. nature Home owner or licensed agent's signature certifies the following: "I certify co that in the performance rn the work for is h ring r su workissued,wmnature pensa- employ any person in such manner as to become subject to workman's compensation lam wsis losfsueddl shall employ W re hiring or sub-contracting sig certifies the following: "I certify that in the performance of the work for which this pe tion laws of California." / The apDlica t must gp11 for all required ins to/rte Compete drawing on reverse idoe. ` Signed X 1 Date: 0 � ��61/9 /,I Title: �! FOR DEPARTMENT USI ONLY Date 7Arsa Application Accepted by Date ata Final Inspection by (),iy�a y {�S Pit or Grout In ction by �, I ZA r tl 4J y l eat 4- l Lo t oma '° t v�AcK A ditionel Comma s: 1 Manteca - 106 wcy V Q.IIL! N Stk 466-Ml ❑ Lodi 369- Applicant - Return all copies to: Environrnentel Health Pemlit/Services 1801 E. Hazelton Ave., P.O. Box 2008, Stk., CA GATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY INFO �(o/ � -�5 -� f, 0 Val 3 s ' . EH 1}111REV. sn �^ ��/. EH 1419 * CL L 01-A, .�/r (� AAn/ Yt 2 t L /��",fF I� ✓