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APPLICATION FOR PERMIT r ti SAN JOAQUIN LOCAL HEALTH DISTRICT rE r: 1601 E. HAZE;.TON AVE., 3TOCKTON, CA Telephone (209) 466-Ml PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;z 1gF (Complete in Triplicate) -j ,, q T1ria rpv ^6Ni t Z , , Kik to construct soarer Mstsn the wont hmein tlesctlbed of lfrr son Jottqu Application is hereby made to the San Joaquin lata!Health District for a peon No•1962 for welllpumP a� Rules and Rpulatlons N �; # ,, made in compliance with San Joaquin County ordinance No.549 for sewage N 1 ,t Local Health District. ` F f "Job AddressC' . lot size Ilk} Phone v rh}� a sriit-., Address ^ KL,w Dwner'�Narne k far 11 c �' r-CAddles- License No. Contract 7�/�'Tr•C.tr NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC7lON ❑ 1 *r°r 4 r" a I 3; ] } TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ , fir rt. Al €X � .}.,F�` z s• .��PUMIPINSTALLATION ❑ ,* x,y I + rr i SEWER LINES DISPOSAL FLG. PROP.LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL an FOUNDATION AGRICULTURE WELL ., ick a •� F u INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tr p Die.of 1Netl Caaing° 1 a ar s • ,F p t❑industrial ❑Open Bottom Q Manteca Dia.of Wa11 Excavation S y ny T of Casing #.r-, } 2 ❑ DomesticlPrivate Q Gravel Pack ❑Tracy YPe Type of Grout Depth of Grout Seal _ ""- [] Public ❑Other ❑ Delta _ +A'. r4- k k°r {i i�C 41 ,>❑ Irrigation �pprox.Depth ❑Eastern Surface Seal Installed by ,�' a ' H.P. State Work Done p 74rr Lr 2s + •Repair Work Done. ❑ Type of Pump R. a ,t ♦ a� p r F ' Sealing Material(top 60') ' Wall Destruction Well Diameter , ws et "q kr Depth pp Filler Ma t(Bel ) oN DcSTRUCTION❑ life septic syatam permitted d public sewer Ise z ;4 4p� f TYPE DF SEPTIC WORK: NEW INSTALLATION Q R available within 200 feet.) Instellawn will serve:„Residence Commercial Other , f ,e " 1� t F+a t yi ' E Number of hedraoms Water table depth Z `� t" + Number of living units: s� J E f}� Criaracter of$oil to a depth of 3 feet: f„ Capacity --� No.Campartnrents a : SEPTIC,TANK ❑ Typ^rMfg Method of Disputa! r � 1 PKG.TREATMENT PLT.0 ;P Property Lina " " ' f 4 pistYnce to nearest: Well- Foundation - Q , Tot e1 length/size c Y -�» "LEACHING LINE Na.&Lengthol lines Foundation Property Line ° FILTER BED ❑ Distance to nearest: Well Number Size SEEPAGE PITS ❑ Depth �� Size_ i 3 T y1a n SUMPS• ❑ Distance to nearest: Well Foundation- Property Lim i s DISPOSAL PONDS ❑ 1 ; r Tea this application and that the work will oe done in accordance with San Joaquin county ordinances state laws and J} I hereby certify that I have prepared •` } •,p.y'�a rules and regulations of tha San Joaquin Loc Health District. I shall not v g:.. _ Home owner or licensed agent's signature certifies the foliowin 1 certify that in the performance of the work for which this permit is issued, ' ".. employ any person in suhiri ch manner as to become subject to workman's mmt+ensation fawn of California."Contract subject to workman ompe!tita certifies the lotlowing:'"I certify that in the performance of the work for which this permit is issued,I shall employ pe tion laws of California.' s . The apPlica must call for aU_ wired inspections. Complete drawing on reverse side• L� I Date: Title: u '� r t� x fl Signed rtC FOR DEPAR ENT USE ONLY p Data iJ Area ' Application Accepted by r 1 Date Date Final Inspection by Pit or Grout Inspection ` t, [ y� Additional Comments: jr` 3 p Stk 486.6781 ❑ Lodi 019-3621 ❑Manteca ffi3-71 p4 ❑Tracy ` 8 r ,r� Applicant-Return all copies to: Environmental Health ParmltlServices 1601 E.Hazelton Avex 2009, Stk., CA 4520 ., P.O.,So11 .` CKSS" RECEIVED BY DATE PERMrT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO &/ter� � �1h� • • s~� EH 1136 fREV../n s1 C-+ Lip `[kE EH t&7E .� 4