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I APPLICATION FOR PCRM JT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZEL T ON AVE., STOCKTON. CA Telephone I209f 455-6781 i - PERMIT EXPIRES t YEAR FROM DATE ISSUED iComp',ate in Triplicate} Application is hereby ma,e to the San Joaquin Local Health DiEtrict for a permit to construct and/or install the work herein described.Thea AppGeat;on r `moi V` made in compliance with San Joaquin County Ordinance No.5549 for se Nat:-or No.16th for well and the Rules and Regulations of the San Joaquin Local Heakh District. Jab address ` 2 Fdyya,, 4 — C;ty_��Ca/0 Lai Si.e� x � �J , PNI r Address �77�{ Phone �•r -- Nome Owner's d e C•.nt recto L Address_ License No__ Phone TYPE OF WELL/PUMP: NEW WELL ❑ W;=LL REPLACEMENT D DESTRUCTION ❑ IC PUN IP INSTALLATION C SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ___ SEWER UNES — DISPOSAI.FLD.____,- PROP. LINE FOUNDATION _AG4ICULTURE WELL OTHER WELL - PITS/SUMPS .% i1 •' IF ATl N :s R CONSTRUCTION SPEC IC O S iNTEN02_D USE TYPE OF WELL PROBLfM P. EA Industria: w Open Bottom a Manua Dia.of Well Excavation _ Dia.of Well Casting 171 Domestic;Privale ❑Gravel Pack C Tracy Type of Casing Specifications r %:;;? ;t y i �, Public C Other C; Delia Depth of Grout Seal .. Type of Grout z C:trigat:or. �pprox. Ceras IF: Eastern Sur ace Seat Ensta6;.d by . ti ,zar :' Repair Work Done i_7 Type ci Pump � H.P. State Work Dane Well Cestruct�on ... Well D;ametNr Seal;ng 44aterial Itop 50'1 ,�'.'r•.y . Death Pler Material 4 I! t Below 501 - � a -*•.r�tr�-. 'rYPE OF SEPT'.0 WORK: NEW INSTALLATION a REPAIR/ADDITION LJ DESTRUCTION i (No septic system permitted if public severer is available within 2W feet_) Installation will serve. Re/sidence Commercial_ Other r I m P:umber o.bedroc s NumSer a. linin units: r g r' :V.;:'=jam•s,' r: S L - n — f _Water t able depth -70 Chac,er d(soil to a depth o4 3 rtieciL�� No. Corn artment sC Capp TANK 7 Type/Mfg 11�__ 1-~. , ; Method of Disposal REArhn=�TP T.wPKG.T1ZI Distaro to nearest: VeFcundatdn Property Line LEACHING !JNF ^'1�D.& Length of lines `oral long': /90 r. FILTER BED _. Distanwe to nearest: Well f — Foundatior.��— Property Line -301 �vr — E Number SEEPAGE PITS C; Depth -� __Size _ SUMPS ❑ Distance to merest Well_ �_ Foundation_ Property Line DISPOSAL PONDS ❑ . Ihi--by certify that t have Pre ar d this aNp iicai on and that the ork will done accordance withSan Joaquin county ar rn3 hoes state laws and r.rles and regulations o: the San Joaquin Local h'cal;h District. m owner or licensed agent's signature certitie:the following:"l certify that in the perfomrance of the work for which this permit a issued,I shall no: Ho.e 8 n n rl n f California.' Contractals Kirin of sulNCnntracting signature .s. m i s col. sz o .aws o - nae•s to bee erne subject to work a l>e 9 n -,erson in such man _ a J _ ampiny.:he.. +� certi�ies the following:"I certify that in the performance of the work for which this Fe:mit is issued,f shall emplay A=rsons subject to workman's compensa- tion laws of California.- for alt required inspetet. .Co I lete drawin on reverse side_TheaPPI'cant must cat! Signed //JiLQ.� T lite: .�� Gate: 96 FOR DEPARTMENT USE ONLY Q L �� ...:_.�-0. ©' Application Accepted by DateArea Pic or Grnut Inspection y —u , Final Inspection bDate- Y Fd d;t°o nal Comments. t rM1 Ci S,k =,66.6181 111 Lodi 3633Cu1 ❑Manteca t32i-7111a ❑Tracy .SL�+ti?IIS 51,V, p.ppficara-Return all copies to:Environmental Health pem±it/�ervices 1691 E. Hazelton Ave., P.O. Box 2009,Stk.,CA 95201 FEE AMOUNT DUE A%!OUNT REMITTEDCAsw RECEIVED BY DATE PERkS1T NO. 0 I17-0 bw (�^ µ F 4