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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA --Telephone•(209).466-6781 PERMIT EXPIRES 1 YEAR'FROM'DATE ISSUED'' " (Complete"in.Trlplicate)d , s„ - N.... Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for se+nra9F} Noonfor weld/pump and the Ryles and Regul osns�f` in —0 l ,Local Health District. - r~•RH1'6Hu�1��"I� i!iAiJ �inoCitjr R+LDpi `Lot Size PM Job Address 602 ii- }}ma�y Owner's Name pd-u15 rnf{S o r .Address 31.1P-.f}:I IZtitY/f . . Cfl57ft.-Mj�4 Phone nRl�[r � - Contractor—LT- cope Address -Sri fiRt�DLD 8�` License No. Phone TYPE OF WELL/PUMP: NEW WELL fl WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F-1SYSTEMREPAIR 11 PROP. ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Zz TSr�4LP. PROP. LINE' k AGRICULTURE-WELL :; OTHER WELL —_.- PITS/SUMPS —' T , . e INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �,y Dia. of Well Casing t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation p . - C��CFZ I r Q VG f S ecifications r.- T ' . ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Z Type of-Grout` ❑ Public El.Other t ❑ Delta Depth of Grout Seal ,� P�OST IOA} DRi L1r A(6. 515RU tCF ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by` HP- State Work Done Repair Work Done ❑ Type of PumpY r Well Destruction ❑ Well Diameter Sealing Material'{top 50`1- 1 Depth Filler-Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 13REPAIR/ADDITION LJ DES] ❑ aNailsep iwri system permitted if'public sewer is �7 Installation will serve: Residence— Commercial Other ._ e _ Number of living units: Number of bedroomsR' Y A I A Water table depth- } }}}lll Character of soil to a depth of 3 feet: No..Compariments SEPTIC TANK L1Type/Mfg _Capacity L i -4,-`' t Method of Disposal"J PKG. TREATMENT PLT. ❑ - - w "++ i if r 'Line Distance to nearest: :Wella 21 Foundation Pro p erf V4. Totai'length/size LEACHING LINE LJ No. & Length of lines , y 1 f 3 Property Line1. FILTER BED E3 Distance to nearest: Well Foundation f 1 � ^ iSize ?i - + -' Number a SEEPAGE PITS ❑ Depth -4"Property Line SUMPS ,❑ Distance to nearest: Well Foundation" DISPOSAL PONDS -. O, - ' l hereby certify that I.-have piepared,this application and that the work,will,be donein ac ordande with San Joaquin county ordinances, state laws, and rules and regulationscf.CherSan,JoaquinrLocal.Health,District. , - Home owner or licensed agent's'signatur`e,certifies the following: "I certif Ahat 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 for which this permit is'issued, I shall employ.persons subject to workman's compensa r tion laws of California." .' r The applican m t call for all requir i sped Complete drawing on reverse sides Date: Z1 1r S Title:. Cy Sighed X , SE ONLY _ Date A a Application Accepted b ,y �Fihal Inspection"b at y i Pit or Grout Inspec 1 y Y f. ate J: Fi w Additional Comme ❑ Stk 466-6781 -� Lodi 369-3621 ❑ Man ca -7104 ElTracy w 83rr6366, Applicant- Return all copies tot Environmental Health Permit/SeMces 1601 E, Hazelton Ave., P.O. Box Y2009, Stk., CA95201 � s FEE AMOUNT T]UE AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. INFO ' EH 1324(REV. EH 14-28