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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appliaion isr install the work cation is madecntcompliance weiebyrith SanoJoaqu nthe SanCounty OrdinaJoaquin lnce No.549 for sewage orHealth District for a 'No. 1862 for welt to construct Upuomp and the Rules and herein Regulations of the San'Joaquin Local Health District. Job Address /V`d' S OP'..M /r} 'lit) OF M-JY '77 City �I � Lot Size PM SDI77`J VFx1Z -fZ� 74> Phone 6 Owner's Name U3lLl-I/9T!] LYONS �• Address Contractor ddress ZS25 M1 . ense No._4a2216_5 Phone 9y8 _13q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER yg 76Si Bp►zfN 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 IS 'to SS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout---- I rout -- 1 Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by_/�}��Ry #04Zs, - g 41-4� l Repair Work Done ❑ Type of Pump H.P. Well Destruction 11 Well Diameter Sealing Material (top 50'1 LZitG Depth Filler Material (Below 501 Dil4r S'01 ff TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth U; SEPTIC TANK ❑ Type/Mfg Capacity No- Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line d SEEPAGE PITS l I Depth Size Number SUMPS Ll 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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 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- tion laws of California." C The applicant must call for uired inspections. Complete drawing on reverse side. X41 G n Title: Pnr+�C-T 66L0L_b6tS1 _ Date: W~16- -LD Signed X F R DEPARTMENT USE ONLY r/ Application Accepted by Date e G Area I Pit or Grout Inspection by Date Final Inspection by D-aty� J Additional Comments: g ❑ Stk 466-6781 LJ Logi 369-3621 ❑t0anteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDH RECEIVED BY DATE PERMIT'NO. INFO f7 11 !�s i EH 13-21(REV. /n 5) S hP 0 •� d EH 14-26 i