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it l :i i 4 APPLICATION FOR PERMIT II SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA II Telephone (209) 466-Ml I �( PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. . ti, , iCom .,_ . . � ,..sf• r. . ;, .:.. Plete in Triplicate).;;, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inistall the work herein described.'TMs application is made in compliance with Sen Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulations of the Sen Joaquin 'Local Health Distnct. '�s •. i; " ".. � oCOO S(1 4�.rr 1 Y1�AC-lA P `H `•r• ..Ci: f� { •Lpt.Size ��+ PM Jab Address _.., i a ,. `__ tl'�- — ,lffl "Owner's Name 1V I diL v' SQ3 f UCe- Address �� G 8O( WG i 02 ON Phone CCntractor 'S�Lr^ Address License No. Phone_ TYPE OF WELL/PUMP: c ,NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION i. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD. PBOP_..LINF __._ "'—'FOUAtyATIONI-- AGRICULTURE WELL OTHER WELL PITS/SUMPS T 'INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION'SPECtFICATIONS r ;Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing _ ❑{Domestic/Private L7 Gravel Pack ❑ Tracy Type of Casing Specifications ❑`Public ❑ Other "' ❑ Delta Depth of Grout Seal Type of Grout__ ❑irrigation --,P,-Approx. Depth ❑,Eastern Surface Seel Installed by Repair Work Done ❑ Type of Pump H.P. •State Work Done k Well Destruction )1. We'll Diameter Sealing Material Itop 50'1 I Depth Filler Material(Below 501 PE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 3. available within 20D feet.] ! Installation erve: Reaidenoe_ Commercial_ Other Number of living units. Number of bedrooms Character of sal to a depthlof 3 e Water table depth SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT.❑ !j - Method of Disposal -Distance to nearest: Well dation Property Line (i r LEACHING LINE ❑ No 8 Length of lines ngth/size _ ..._e _ .FILTER BED ❑ Distance to nearest: Well Foundation '-Pro Line li -r SEEPAGE PITS ❑ -1DepthSize Number SUMPS . ❑ ,Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ `I _ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinaRces,state laws, rules and regulations of the San Joaquin Local Health District. I Hone owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work.tor which this permit isissued,1 shall employ persons subject to warkman's compem5a- tion laws of California." The'applirant must I�for all gored in tions�Complete drawjpg on reverse side. A =z� 87 Sig d X A" GI �6�rtle: 4 .. (�'I.t.rt�iF Date: FOR DEPARTMENT E ONLY �--1k Ll . __ /� Applfcatign Accepted by wr ^� Date � 7 � Area 11' :Il. Pk or Grout Inspection by p Date_-. Final Inspection-6y Date,-. 1 Additional Comments: _ - ❑ Stk 4866781 .❑ Lodi 3643621 ❑ Manteca 8237104 4 ❑ Tracy 835-8385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 r FEE AMOUNT:DUE - AMOUNT REMITTED CK RECEIVED BV' DATE PERMIT NO. � INFO SEH r3N IeEV.'1Jn E) ' V�-ter