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` APPLICATION FOR PERMIT ' +, SAN JOAQUIN1OCAL HEALTH DISTRICT 1601 E. HAZEL TION AVE., STOCKTON, CA ; Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED rl :, P. (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d t' + �.. made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin f Local Health District. y described. This application is Job Address City .S G Lot Size PM owner's Name � r Address -- _ Phone Contractor f - TYddress .�/Z GD PE OF WELL/PUMP: NEW WELL ❑ License No. '�8��_Phone PUMP INSTALLATION WELL REPLACEMENT ❑ DESTRUCTION 1J � DISTANCE TO NEAREST: SEPTIC TANK , •- - - - .. -� SEWER SYSTEM REPAIR El OTHER E3 LINES `y FLD.DISPOSAL DI PROP. LINE AGRICULTURE WELL-•.,s INTENDED USE OTHER WELL_ PITS/.SUMPS.-� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Mdustrial ❑ Open Bottom ❑ � Man Dia. of Well Excavation Domestic/Private Ll Gravel Tracy Gravel Pack Dia, of Well Casing El Public Type of Casing ❑ Other ❑ Delta Specifications 11 Irrigation Depth of Grout Seal --Approx. Depth C1 Eastern Surface Sea! Installed TYType of Grout Repair Work Done ❑ Type of Pump I❑ Well Diameter=.� by / Well Destruction —�� H.P. Z State Work Done Sealing Material (top 50') ANT TYPE OF Depth I Filler Material (Below 50') SEPTIG WORK: NEW INSTALLATION L1 REPAIR/ADDITION ❑ bESTR1ICTION ❑ {No septic s stem Y permitted'rf public sewer is � Installation will serve: Residence_ Commercial: available within 200 feet.) • Number of bedrooms Number of living units: Other UV Character of soil to a depth of 3 feet: CA SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT, ❑ Gapacity -� Na, Compartments Distance to nearest: WellMethod of Disposal i Foundation— Property Lineall LEACHING LINE ❑ No. & Length of lines 'J FILTER BED ❑ Distance to nearest: Total length/size Weil Foundation Property Line�� J SEEPAGE PITS ❑ Depth ._, J Size SUMPS T; 4�.r ❑ Distance to nearest: Well Number - { �'--D)SPOSA-L PONDS ' --,Foundation ❑p -��, 1.- .,« w ; Property Line I hereby cr flu$lathais have pr rkpp!d this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the S ► oaquin Local Health District. Home owl►&NW4iCen�age r'at. nature certifies the following:-7,71_ employ any ' p Y q,- wi ink uch manned as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting si n g: !,certify That in the performance of the work for which this permit is issued, I shall not certifies th 'fo lowing. "I certiNtGt in the performance,of the work for which this permit is issued, I shall employ tion laws f,0a ifornia• g g azure -s , p Y persons subject to workman's compensa- The applict mu i o alb iced inspections. Comp+ to a drawing on e�•de'T'-,�--� r+.� Signed `"` A- - ----�� -� P ry ,srS Y Title: t � te: s- i � ,�-- FORD RTMENT USE,.ONLY - Application voce i Date Area Pit or Grout Inspection by I y I Date Final Inspection by GJ Additional Comments: Date- ❑ Stk 466-6781 ❑ Lodi 369-3621 1.'?J. ❑ Manteca 823-7104 ❑ Tracy`'f835 6365 f Applicant- Return all copies Co-'Environmental Health Permit/Services 1601 E."Hazelton Ave., P.O. Box f 2009, Stk.;CA 95201 _ ff LAMOUNTEDUEAMOUNT REMITTED \ CK -1 �-ti-RECEIVED 8Y CASH DATE PERMIT"NO. EH 13-24(REV..7/85) EH 14-26 (��• . .s 1Z7