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4 �. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2019) 466.6781 j PERMIT EXPIRES 1 YEAR FROM DATE ISSOED f CNrrtp;,.te in Triplicate) Application is heiehy made to the San Joaquin Local Healrh F)isir.,;t for a Pt"lir to ronstrncr amdlor instt,li the work herein described.Tins application is made in COrtlj,lian Ce with San Joaquin County Orginar,re 1,m ?o-19 tar s,-wa<lea or No. 1862 lar wall;pump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address - C' Lot Size PM _ ---- / Ownei'.s Name Address l � phone _ f �-F�: ConlraCtorf"vl�^ f2QL� Address s7,�f � .R --- - License No. Phone ��"Ztr•',f� .c TYPE WELL/PUMP: NEW WELL i.I WE:LI_ REPLACE.4FNT f.I -- a DES i RUCTION L:1 PUMP INSTALLATION ) SYSTEM FIEPAIR I_i DISTANCE TO NEAREST: 5 OTHER ❑ x SFAVER LINF- A ----- AN DISPOSAL FLO. PROP. LINE FOUNDATIO—� ',GRICULTLRr,E WELL _ OTHER W_EL!_. - PITS/SUMPS i!Y INTEi!DED USE TYPE OF WELL PROBLEM A -A• CONSTRUCT-It?'J SF'EI-FFICATIONS �^ Industrial -- -- - ^ti FJ Ogen 3ottom Ci klanre,,:a ice)a hf WI !I 'xr peahen__--- > Dia. of Well Casing D Domestic/Privatµ -- L�7 Gravel Pack y(. o ng.__ � .;H .+ L� Trt�CY T 19 t C �a F'1 Public Ci Other ----- - Specifications Del",, fleet':of(ir{)J[ Seat ._-�._ - Type of Grout�- 13 lrripa+iqn --- -- of Pu ..Deptft { Ea:,turel surface Seal Instalidd by ' M Repair flak Done " Type o`Pump li ;� Well Destruction - Sta:e Work Done w Cf Well Mameter $•'aing Mnterfai flop 50') Depth -- 5 t ^ TYPE OF --IGN I I - _ - _ SEPTIC WORK: NEW INSTALLATION I I I':. ',�!;•F,Itt)r110 ! OES7RLJCTION I i (NO septic system permitted if public scwr;l-' Installation will serve: Residence-- available within 200 feel. COmmerr,a� _ _. :r. Number of living units: Number of bedrooms aCharacter of sail to a depth of 3 feet:_ _ _ Water table depth 5v SEPTIC TANK C7 TypeiMfg � - Capacity---� " PKG. TREATMENT PLT. Il. No. Compartments _�- Y --- Method of Disposal -� Distance to nearest' Well_-__ _ Fnundaiion " �--- Property Line tq LEACHING LINE _ _ F No. &Length qi lines -�_ _ �d-f 7Otal length/size- i 4 i FILTER BED f3 Distance to ntarest: Wi!V (GY —— �- Foundations._- Property Line _ SEEPAGE PITS .L Doptl. _ Z�� "-- -.Sire.. Number_� 6 SUMPS Li Distance to nearest: i' C/ F DISPOSAL PONDS Ci •.>undaGon-- -�-- Property Line--11-<L — I lesahereby certify that I have pr tparedSan this application and rivet t±:e wurk pall!�L d,u1e in accordance with San Joaquin county ordinances, slate laws, and 4 i •� rules and regulations of the Sart Joaquin Local Health Oisrricr. Home owner or Ir enSed agent's signature cer+ifies the lollnw:ntl: "I CV01V[lilt in theworkfor s employ any person in such rnannor as tq become subject to wnrkrnan's rprnpensation laver,otnCalifo of Contractor's Th opsub!conrssued,f shat!not r certifies the following:"I cerIJ that in the rforntar•.co of the%vnrk for which this permit is issued,f shall employ Y pe p tion laws of California," i p y persons subjoct to workman's compensa- s Tha applicant RtuA C er a!I requirspg s. Cornplutu drawing on revur5o side. it Signed - - Tit;e: 14 Dste: - _. �.—� 1 Fes-DEPARTMENT USE ONLY Application Accepted by ,.. ❑rite --�-� Area t or Grout Inspaction h i' Y Fwaf Inspection b T/ Y, c� Date Additions!Corn:nents: I ❑ Stk 466-6781 CJ Lodi 359-31321 _CZ Mantec, t-1 Tracy 835.6395 _-�'----- Applicant• Return ell copies to: Environmental HeBith Pemrit ;;e,vicos 1f0t E, Ha:olton Ave., P.O. Bcx 2009, Stk., CA 95201 s P , FEE '--'-�--- _ INFO AMOUNT Dt1E AMDU.•1T FlEtV,Yi'rED CK z RLCEfVrO ftV _-_�- CASH DATE PERMIT-N4. lI • Eli 13.24(REV,i r•sr ! -" ---