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^; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTW DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Complete in Triplicate} Application is hateby made to the San Joaquin Local Health District for o permit to construct and/or install the work herein describod,This application is made in compliance with San Joaquin County Ordinance No,549 for sawago or Na.18652 far we8lpvmp and the Rules and Ruguiations of the San Joaquin Local Health District. 1 I Job Address, l�tZ r Gym L O G1 l „-,_, City�fl q.!_� Lot Siro L-" JJ _ PM Owner's Name.tea �( f�l�[I e S v Address :�,4" _ Phone 2GB-- C on t r a c t orl- $=Contractor [wji g� S,jpC/iddiess zg�� Q— License No. Phone_2_�Lt-I 5 TYPE OF WELLIPUMP. NEW WELL 9 � WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER SA Nttl.tirlr.y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS H ❑ Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation /o Dia,of Well Casing y ❑Comesticiptivate q Gravel Pack ❑Tracy Type of Casing r L Specifications ❑Public 0 Other fANC��J 0 Delta Depth of Grout Seal '-j� Type of Grout�l,S e ❑Irrigation 4;0�Apptox.Depth M Eastern Surface Seal Installed by :18,K- Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 501 _ Depth T Filler Material(Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION❑ DESTRUCTION L7 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve. Residence A Commercial— Other_ Number of living units; Number of bedrooms.— Character edrooms._Character of sail to a depth of 3 feat: Water table depth SEPTIC TANK Q Tyf.e1rAfg Capacity No.Compartments PKG.TREATMENT PLT.❑ JMethod of Disposal Distance to nearest: Well Foundation_ Property Line LEACHING LINE ❑ No.&Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth --Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance3,state laws,and rules and regulations of the San Joaquin Local Health District. Home 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 I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring tar sub-contracting s.'gnature certifies the following:"I certifythat in the performance of the work for which this permit Is issued,I shall employ persons subjRct to workman's compensa- tion laws of California;' The applicant st call for lLcuquire i actions.Complete drawing on reverse side. p �J Signed Title: Date: i A IVT USE ONL Application Accepted Date — Area Pit or Grout in ct' by � Date Final inspection Date dt,tl�.�5 �,� 'c�dhiona!Comma i,__;$tk 46 Cm781 ❑Lodi 369-3621 0 Manteca 823-7104 0 Tracy 8354385 rApplican,-Return all copies to:Environmental Health Perot/Services 1601 E, Hazelton_Ave.,_P.O._Sax 20D9,_Stk„CA_95MIFEE INFO AMOUNT DUE AMOUNT REMITTED ASR RECEIVED eY -�rDAiE pPEnAit7 NO. - . ♦ Eli M241REV.Yr851 E 7 r••y d EM14-75 1 -