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APPLIrATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i'PV til✓". Telephone 1209) 466-6781 'P, �'E!V PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hatehy made to the San Joaquin Local Health Disir.et for a permit to construct and/or install the work herein described.'This applicationa��'�M} made iii compliance with San Joaquin County Ordinar ce No.549 for aewage or Na.1ti52 for wslllpump and the Rules and Repul,' ,!`5 y4t�C6 Local Health District. �1 PERM'13��ERv I Job Address J�al�3 lr �L �r 2 ��id9e. City 6.sZLt�� Lot Size PM Owner's Name 'C'v PYl7Cl C 0. Address L- moi!lClt�n (ail �� '�D 3 Phone - a' Cantractar1 �nG Address 1� o6e vd e, CA ?5�—,7� License No. 2 .55_5(a-_Phone ' - 7 33 a? TYPE OF.WELLIPUMP: �. NEW WELLS WELL REPLACEMENT ❑ DESTfiUCTION C1 - p�?C C- 5c'L' PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER Q QviC(o5e[fO�- plan _ DISl'ANCE TU NEAREST: SEFTlC TANK SEWER LINES DISPOSAL FLD. PROP.LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ��1 V � l r' Q Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation Dia.at Well Casing Q Domestic/Private gavel Pack ❑Tracy Type of Casing � � Specifications �� [1 Public fl Other n Delta Depth of Grout Seal - Q 1 Type of Grout ' I I Irrigation -Approx. Depih I I Eastern Surface Seal Installed by 4. s - Repair.Work Done Q Type of Pump H•P. /State Work Done Well Destruction ❑ Lhle[I Diameter �/ Sealing Material flop 50') )9)Vci1i4Ty-,n o Depth r=Ca 5'�I �901 Filler Material IBelow 50'1 =OF TIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I fNo septic system permitted it public sewer isavailable within 200 feet.)'[!serve: Aasidence Commercial_ Other }:.. Number of living f lumber of bedrooms r Character of soil to a depth feat: —Water table depth x SEPTIC TANK ❑ Type/M g Capacity No. Compartments 'r. PK'G. TREATMENT PLT.❑ Method of Disposal r . �s Distance to nearest: Well Foundation Property Line r- LEACHING LINE ❑ ^Sa. & Length of lines Total length/size s FILTER BED '`' Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11: Depth Size /dumber r SUMPS L] Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS. ❑ 1 hereby certify that i have prepared This application and that the wark will be dune in accordance with San Joaquin county ordinances,state laws,and €r" rules and regulations of the San Joaquin Local Health District. o- Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this permit is issued,I shall not 2 : employ any person in such manner as to become subject to wwkman's compensation laws of C35fornia."Contractor's hiring or sub-contracting signature ceitifles the following:"I certify ih3t in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion[aws of Calif he applicant u call for all vire speons.Complete drawing on reverse side. /�� (y(Jr/L!/t� . P� cls � Signed Title: Date: � FOR DEPARTMENT USE ONLY --- -- - Application Accepted by, tL4�,ls L.. �S 0 �— Date Area o-� Pit Grout! spection by Date- Final Inspection by Date t :. r , Additional Comments: EJ Stk :466.6781 0 Lodi 30.3621 ❑ Manteca US-7104 ❑Tracy gi5-838fi Applicant Return all copies to:Environmental Health Permit/Services 1601 E.Hazalton Ave.,P,O.Box 21109, Sik., CA 95201 S IJ� G.T. :C1(1~frr G c�#s4bZ e FEE AMOi.NT DUE. AMOUNT REMITTED CAS_H RECEIVED BY DATE PERMIT'NO, INPO r {2 EEli H 1{24 IREV.t(N!5; a k I JN