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APPLICATION FOR PERMI s SAN JOAQUIN LOCAL HEALTH DISTRICT i} 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (249)466-Ml PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;)�g (Complete in Ttiplicate) Application h hereby made to the Sen Joaquin Local Health Oiatri^t for a penult toconrtrthet and/or Mtsrall tM work herein darnead.Thin app�dlln made in compliance with Sar.Jasquln County Ordinance No.548 for sawape or No.1882 for wa0lpttrnp and the RuW and Rap+'atloete of tfir Ban.1o$qutn t ' r Local Health District. { j" ar 3 o s A' cityiC'Q.Si . z � P. Job Address �.r~Address �ac�pcas�--- Y ,,r2 . ' Owr»rs Name /+ L Q, _ 7 O rh!Phan, r t: G LJ�•' "�� Address License No. i�s� ' t •ff Contracts i F TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O 1 n j DISTANCE TO NEAREST: SEPTIC TANK SEWFn LINES DISPOSAL FLD. PROP.UNE FOUNDATION nt!IICULTURE WELL OTHER WELL PITS/S'.lMPS ct, INTENDED USE Tyr E OF WELL PROBLEM AREA CONSTRUCTION SPECIFI TI /� ❑Irrdustriel 0 Open Bottom t3 Manteca r ola.ur wail Ex Dia.of woo qr ❑Domestic/Privste ❑Gravel Pack ❑Tracy Type of Cosi f— t ❑Public ❑Other ❑000 Depth or Grout Seal TYVe at Grout 1- * ❑litigation .�pprox. Depth C�,Eastem 5f Seal Installed by , r f 1 ! Repair work Done ❑ Type of Pump �U H.P.— Stste Work Done r p . §` Well DestruCion ❑ Well Diameter Sealing Material(top 50'} r , + _, Depth filler Materiel(Below W) I , TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIA/ADDITION❑ DESTRUCTION❑ INo septic sYatanh psrtnittad if public nitarrar ra r available within 20D feet.) } Installation vA''A serve: Residence Commercial Other f ; Number of wing units: Number of bedrooms water table depth = Character of soil to a depth of 3 feet: �7 Capacity No.Comparlrnents L t SEPTIC TANK ❑ Type/Mfg / + PKG.TREATMENT PLT.D Method of Disposal {i� 1 Distance to nearest: Well Foundation.^ Property Line _{ ;,. ►' LEACHING LINE ❑ No.a Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundetkon Properly`one f i i iln SEEPAGE PITS ❑ Depth Size Number SUMPS C3Distance to nearest: Well Foundation Property Lina qy' DISPOSAL PONDS ❑ l 1 hereby certify that I nava prepared this application and that the work wiEl bo done len accordant: witti San Jaaq!'n county ordktartces.urate 11"S.and rules and regulations of the San Joaquin Local Health District. Home owner of licensed agent's signature certifies the following:"I certify that len the performance of the N A for which this pem*Is Issued.I shall trot employ any person in such manner as to become subject to workman's compensation laws of ColifrYnie 11 ..ontractoes hiring or sub-contracting slprtah" certifies the foMovring:"I certify that in perlorrnance of the work for which this permit is hared.I :.".employ persons subject to workman's wtrnpanaa i 4 tion laws of C ilifo�ia." Gy The applicen s -call} r e11 In ilio t drawing On r side. i j Da!a: ' ��6-40? + Signed Title: " FOR DEPARTMENT USE O:LY Application Accepted by Oats – Ana f Pit or Grout Inspection by i 4 i Date Final Inapecaon h/ Deft. Additinnel Comments; ❑Stk 4668781 ❑Lodi 362f ❑Manteca 823.7104 ❑Tracy FaS 6XX Applicant•Ratum as copies to:Environmental Health PormitlSarvicns 1601 E.Hezehan Ave.,P.O. Box 2008, Stk..CA 962;1 FEE AMOUNT DUE AMOUNT REMrTTED CASH RFGt:IVED 6Y DATE PERMIT' INF;1 ]��{ •fir 1� y/W�/•rf1/ . EN r}MIRfV ' Eft lam r 1� r }