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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED_ (Complete in Triplicate) Joaquin ll the work .This made Application compliance heiriby writhde to the Joaquin County Ordinance Na 549 for sewage or ealth District for a permit 1862 for construct Upump and the Rules and(Regulations of the Sao Joaquin Local Health District. uV city Lot Size PM �jge% Ye"!2 — Contractor y Job Address --J�N-�-"- ``�p V N Phone Address Owner's Name g/ ! Bl q,�s / `�1� /N�/LJ/� CL License No. Ps.... Ll TYPE OF WELL/PUMP: - - NEW WELL D ----- WELL REPLACE - --��_•6E5"<�10THER❑� 1 PUMP INSTALLATION SYSTEM REPAIR ❑ tE `I}1 DISPOSAL FLD. PROP. LINE N DISTANCE TO NEAREST: SEPTIC TANK SEWER LIS k LEl_z T49RE-W ^#TER-WEL•l—...=PI75/Sl1MP$ I FOdNOA-TaON ry d } AGRIC 1V" - INTENDED USE TYPE OF WELL PROBLEM AREA.;,�.GONS�AUGTI�N�SPECIFIGIONS ❑ Mahteca'�'�Oiarof�ie8-Excavatfon`--='- Dia. of Wall Casing ndustrial ' ❑Open Bottom I / t Type of of Casing Specifications , ❑ Domestic/Private 0 Gravel Pack O Tracy I fl 4he Depth of Grout Seal Type of Grout I"11 Public E ❑ Other _ I`I Inigatio� 4 �APProIK Depth l Eastern Surface Seal Installed by I •/R� I �`" lz H.P.—.�� State Wirk Done f S•/_� 1 pair We Done Type o_Pumtf Well Destr Iction ❑ .Well Diarnele`;,1 Sealing Material It p 501 h IV lkpt� Filler Material(Below Sa TYPE OF SEPTI .!WORK: NEW INS .i LLATION I jREPAIR7ADDITION I I DESTRUCTION I I,� 1 lijo asp �ilable within 200-feia1lad it public se wor is 1 ({ Installation vin !serve: Residence_ Commercial[_ Other I ' I Number of be}roofs I i t6 Number of living units: t ) Water table depth i �/J`'Character of sail to a depth of 3 feet: I p No. Compartments 4SEPTIC TANK fes. —�Type/Mfg ( Ca achy Method of Disposal I PKG. TREATMENT PLT.❑ Pro Line Distance to nearest: Well Foundation I Y rt ` ( I Total lengthlsize 1 { FILTER 0 LINE ❑ Distance & Length ar lines Property Line II FILTER 8`D ❑ Distance to nearest: �Well Foundation 1'1 I Size Number SEEPAGEIPITS I I Depth I SUMPS 1_1 'Distance to nearest: Well Foundation Property Line ' ` DISPOSAL PONDS ❑ ` I hereby clirtify 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 ieguiations of the San Joaquin Local Health Dilarict. ••>--e h Home owner or licensed agent's signature certifies the following "I certify that in the performance of the�oSk-for which ibis permit is issu in I shall not employ an4 person in such manner as to become subject to workman's compensation`laws ofCelitoinia,"Contraptor S'hiring of sub-contract signature certifies the following:"I certify that in the performance of the work for which this perrllit�s�issued'1 d5a11 employ persoru sect to work�;s compensa- tion laws of California _ The applicant must ail for all quired inspections. Complete drawing on raver a ids. Title: Date: Signed X _ FOR DEPARTMENT USE ONLY p 157 Date Area i Application Accepted byZan C, I - Date Final Inspection I Pit or Grout Inspection by Date Additional Comments: ❑ Stk 466+8781 0 Lodi 369-3621 0 Manteca 873-7100 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 I 'I OK RECEIVED BY OATe PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH I INFO ❑�1 ..EH 13-361REV.Ve5r ` EH 1436 J