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APPLICATION FOR PERMIT A ``AN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 2 19P'� (Complete in Triplicate) ��tt��1��(( N �NfiAI HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work'h�Tdi �l�lrI ��F5 T� anon is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and R k'f1�EDmAelegJoaquin Local Health District. C/ y,, / Job Address ;x.10-5 L•?Un71 (.� (2tab blvd . ///�� -Inn / ' Citv(��U`(�*�,�/"J I Leot ize � PM Owner's Name vron U�� Address / �• rn.' •�1/x/"!t •1�•-.t•/�•1•J.3^( Y�phone ��5— �a— 95 f�ac+f;c r nvfrmmentetl 1601 l.C` i/v�)Ic Ce r LF- ' ,�'j� Contractor Illf_ Address `IAII�� `1//zrQ License No. '9'6 _ TYPE OF WELL/PUMP: NEW WE - _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHERt l fC DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS >' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS hl L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Welf Excavation .3�/ O N Dia. of Well Casing Y ❑ Domestic/Private Kt Gravel Pack ❑ Tracy Type of Casing �7C vC, Specifications I'I Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout_. "4) I I Irrigation JC.1.Approx. Depth-! I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State ork Done 4 Well Destruction ❑ Well Diamet r ^�• Sealing Material (top 50'1 .� + v J 7" v Depth^'• Filler Material(Below 501 t?AaLl p2cr, TYPE O WORK: NEW INSTALLATION !1 RF?AIR/ADDITION 1 I DESTRUCTION t I (No septic system permitted if public sew r is7 available within 200 feet.) in fil, serve: Residence_ Commercial_ Other Numg units: _ Number of bedroomsCharit to a depth of 3 feet: S �- ter table depth EPTI ❑ Type/Mfg CaDaci[y No.Wa Compartments PKG. WaT PLT. ❑ Method of Disposal /1 (� Distance to nearest: Well Foundation Property Line LEACH11( E ❑ No. & Length of lines _ Total length/size ` FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS 1 I Depth Size___ Number SUMPS LI Distance to nearest: Well___ Foundation DISPOSAL PONDS ❑ property Line I hereby certify that 1 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 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 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: "1 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." �j ..{.� The applicant ust call for all required inspections. Complete drawing on reverse side. '"�E Lt•'C�!' C.l. 'S/ I`- n-up Signed x Tl'c 1�C',.i c f � 02l, � —_ trop; Date: Ct�G -rQ/,•CO L� =X17• �//+ FOR DEPARTMENT USE ONLY Application Accepted by LI'L /71-`,.�C ��,(' ,4� Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6701 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFOfilISS RECEIVEDBV DATE ZPER:M1T*9N0 • EH 1124 IREV.ve 5)