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APPLICATION FOR PERMIT SAN JOAQUIN _OCAL HEALTH DISTRICT 1601 E. HAZE:TON AVE., STOCKTON, CA Telephone (209) 466 6791 PERMIT EXPIRES 1 YEAH FROM DATE ISSUE) (Complete in Triplicate) Application is M,tebv made w the San Joaquin Local Health District for a permit to ennstruct and/or install the wort herein descritwd. This apptrcatton,. msrSn in compliance with San Joaquin County Ordinance No.5.1,2!or rewags or No 1462 for well/pump and the Rules and Regulations of the San Josgtuin Local Health District. 4 / I �. {"L�t r. City.�i-- Lot Size, A�. �' PM Job Address - -- -------- Owner's Name _ 9k__2� Adtl•e3s p Contractor Address_ License No. Phone II TYPE OF WELL/PUMP: NEW WELL O WE L REPLACEMENT C1 DE57RUC7ION O PUMP INSTALLATION ❑ STEM REPAIR CI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _� SEWER LINES _ _ DISPOSAL FLA. PROP. LINE FOUNDATION -y AGRICULTURE WEL _ OTHER WELL PITS/`;t,tMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI P_ECIFICATION_S CT IndusMsl O Open Bottom [1 Manteca Dia. of We!I Exc n - Dia.of Well Galway r, Domestic/Private ❑ Gravel Pack U Tracy Type of Casing__ -__-_--___ Specifications 1� T of Grout 1 ' F1 Public fl Other n Delta Depth of Grout Seal ypia I i Irrigation _._ Approx. Depth I I Eastern Su'facM Seal Installed by Reprw Wort Done [-I Type of Pump _...-___-- H P...__ -�—_-- State Wot one- We11 Destruction ❑ Well Di.-mater _ __ Sealinq latenal ltop SO'! - Depth hiller Material IBelow 511'1 --- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No haptic system pxfmiusd to pubitc to~ is avabble within 200 feet.) Installotlon w11 serve: Residence_X Commetcol___ -OtMt Number of living units: _]- Number of bedroom Character of soli to a depth of 3 feet ____-Water table depth SEPTIC TANK fl TypeiMfg -- ---- Capacity -_- No. CompartmRna ; PKG. TREATMENT PLT.Cl Methurl a Disposai Distance to nearest: Well__. Foundation Pr 'A MY LinSIMMONSe i _ Islu., ` LEACHING LINE --0 Pio. &Length of lines 4-=-��T- - - _ Tote)WVth/airs FILTER SED O Distance to nessraat: Well-_ T Foundation AJ- __ Property Line_:a4�. SEEPAGE PITS 11 Depth Sirs - ftumbeir.� SUMPS L1 Distance to r-s~: Well_ -QL7 Foundation_� Property Lina ` 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 ordinances, state iaws,and rules and regulations of the San Joaquin Local Holifth DAtrict. HonTa owner or licensed agent's signature coniflim the following: "I certify that in the poJormance of the work for which this permit u ra:ued, i not employ any person in such manner as to become st'hject to workman's compensation laws of California."Contractor's having or r, ti-contructing c;oawre certifies the foilowloy:"I certify that in the performance of the work for which this pert-nit is issued,I shell employ peraone eub}ect to workman's tbrnoenss- tion Iowa of California." The applicant at I f irF r;c4n%4d in ions. Complete drawing on reverse side. _ _�- _ n.�� $ignad h.-_ Gt{t -s� { s ?s "__�_'---- Title: _. IL%�- Dab: DEPARTMENT USE ONLY J .c 2 YI a Application Accepted by - Date. Area / Pk Grout Inspection by to f'ktal I"Swtlon by L✓ / Additional Comments: -- O Stk 16,7.6761 0 Lodi 383.3621 ❑ Menteca 823-7101 0 Tracy 835-SM Applicant. LTatLxn alt copim to: Environmental health Parmit/Services 1601 E. Hazetton Ave., P.O. 6or-.1000, Stk., CA 96MI FEE CK t--'-- -----�__.�r�.._._._...��1 INFO AMOUNT DUE AMOt1NT REMITTED CASH RECEIVED BY DATE 1 MiAWT W. -76,60 7G,a0 ..fMti811111Y.tintL [H ills .�>•. -...,....,r+rt,+r�rimre,•r:� :nili.;rCdMr�+C�*..:�y+a,walkS�WJk4bi►�k+li'�.�A'a+:r � - �t _ . . ,.