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30 � APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ! Telephone (209) 466-6781 Vnv w PERMIT EXPIRES 1-YEAR FROM DATE ISSUED fl (Complete in Triplicate) Appi,catiun is heiehy made to the San Joaquin Local Health District for a permit to construct and/of install the work herein described. This application s made, u,cr,rntil1,rnlel vJilh San Jgaqu n County OL(linanro Nu,,549 IU?Stlwd a oN) 1862 for welllpurnp and the Ri lus and Regulations of the San Joaquin local fteaur, D,st„ct ,... l Jot) A(Jdrn;55 f”`-' - L,_:1✓. r i.l= �- -..�_� -- - City -- Lot Site Uwnr;r's Namr: �� tM , - .�f.al��''Ik.._. _ Address _�L C' �.-...�.st----L�Li..' f=-- -L�rf� _ `i '.�-. F'h[uu• i � ' ..•r- .? (" C;onlE.lctn .f,. _-i it l I L._______Address' L'cense No- _i::`J_) 1. .� Priorw TYPE OF 4VEI.I..f Uh1P NEW WELL i"i WELL REPLACEMENT DFSTROCTION , PUMP INSTALLATION 1 SYSTEM REPAIR i ' OTHER i7: DISTANCE TO NEAREST. SEPTIC TANK ''_� - SEINER LINES �S' % - - DISPOSAL FL.D._, __- PROP. LINE I FOUNDATION _ AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y i i Industrial i_l Open Bottom ❑ Manteca Dia. of Well Ewcavation -Ln-L- Dia. of Well Casing - 1 E f Domestic/Private WGravel Pack El Tracy Type of Casing S 0 t i Specifications L I'i Puhlic I I Other I 1 Delta a Depth of Grout Seal -�L)-1 s ��- Type of Grout �%FvieIrf Y•�/` * Irn� uun S��TJ0.p1>.o■. Depth I I Eastern Surlaca Saul Installed by '1�r1 r(r G1y fl1 C.+ t •rar Repan ork done I 1 Type of Pump _ H.P, State Work Done Well Destruction i i Well Diameter _ Sealing Material ltop 50'1 + Depth -.Filler Material(Below 501 _ TYPE Of TIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Wo se . yslem permitted if public sewer is T:c av le within 200 feet.) Installation wr serve; Residence _ Commercial_ Other Number of living nits: Nurnber'Of bedrooms '" r Character of sail to deplh of 3 feet: Water table depth SEPTIC TANK Type/Mfg ' Capacity No. Compartments PKG, TREATMENT PLT:Cl I Method of Disposal f D' to nearest' 4� ,Web Foundation Propeny Line LEACHING LINE Cl No. 8 Lertgof I Total length/size FILTER BED Cl Distance to °? Well Foundation Property Line SEEPAGE PITS1 k Site Number' SUMPS t.l Bance to nearest: Wall ion Property Line DISPOSAL PONDS 1 hereby certify that I have prepared Ihis'a pp1ication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certily that 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."Contractors hiring or subcontracting signature certifies the following:-I certify that in the performance of the work for which thisperrpiI is issued•1 shag employ persons subject to workman's tompensa- k tion laws of California." pa L t t t all I The applicant must can for all criked inspections. Complete drawing ew-awree-side. Signed X Cpl yr [t �� t ►?[. Title:_f C�)67-i-FOste: - _ {i}s FOR DEPARTMENT USE ONLY I Application Accepted by �" �npr"((� Date Y Area a I Pit or Grout Inspection by Data Final Inspection by Date t Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Maniacs 823-7104 O Tracy 835.6385 Applicant - Returnallcopies to: Environmental Health Permit/Services 1601 E. Ha zelton Ave.,/LP�.O. Bou 2009, Stk., CA 95201 Jr'.ti"t+r..� �' i r •1 f^p"''�S �L-. �.C�Vo..o� •` 4A v FEE jc,uS INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED @ DATE PERMIT-NO,