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'r ['[ I% APPLICATION FOR PERMIT ♦; {'v-,. SAN JOAQUIN LOCAL HEALTH DISTRICT : 1601 E. HAZELTON AVE,, STOCKTON, CA epI} n@ iiY.7} Telephone(2 'r,apWp xvi� I `,.:� ,i 'M1 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � (Complete In Triplicate) r icetlon 4 Apel hereby made to the San J osquln Local Hearth District f i� Mede to cVhhpnenae with Sen J or tI P�nwt t. cor2 for and/or lintel ft swxk herein daactfbed.This app ifbEl it r Joaquin County Ordinance No.549 for serhrape or Iia.18&2 for wel[/ptmhp and the Rules and 'v `�• Local hea7Lh DhlricT. Rapttlatioths of Lf+a Ban Joaptritt F4r Job Address C� t d 1t � _City,J � 6�1 Lot She PM Owrhers Name n e, Address :.. ., Contractor r Address t � License No. �� TYPE OF WELL NEW WELL, 1:1 WELL REPLACEMENT ❑ DESTRUCTION ❑ ( PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q A 3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE = o .�a` . FOUNDATION AGRICULTURE WELL OTHER WELL :• ; PITS/SUMtsS '' ;:�y,•;Y; ti SNTENDEfr USE TYPE OF WELL PROBLEM AREA CbNSTRUCTION SPECIFICATIONS i'+ya',$r ,' ❑industrial ❑OpenSottom ❑Manteca Dia.of well Excavation Dia.of well Casing }j ❑ Domestic/Private ❑Gravel Pack ❑Tracy Type of Cast SOacWcadons C1 Public ❑Other ❑Delta Depth of Grout Seal Type of Grout s Irrigation --Approx. Depth ❑Eastern Surface Seel Installed by Repair Work Done ❑ Type of Pum p H.P. State Work Done I Well Destruction ❑ wen Diameter Searing Material Itop W1 =Y #!xX Depth Filler 117eterisl{BefO1v W} + TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIg/ADDITION❑ DESTRUCTION Cl (No septic system Poll nit if public is — available within 2011 feat.lf installation will serve Residence_ Commercial Other "' r1 Number of riving units: Number of bqdroorns . ' I Character of soil to a depth of 3 feet ^- r z,•'ay }c{: Wow table depth a^F: SEPTIC TANK ❑ Type/Mfg ^-lam Capachy�a l� b w No.CnparlrHnts i^ hR y PKG.TREATMENT PLT.❑ fi f Method o1 Dit➢osei a 7N rj Distance to nearest: Well_ Foundation . * :a A. Property Line LEACHING LINE Na.S Length o!linea ng Total length/si" ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,t ,r SEEPAGE PITS Depth .------ Site-- - - Number :tt r SUMPS ❑ Distance to nearest: Wall ir„. Foundation_aE” Property Line_ SC] — •nl , .+:`�'' DISPOSAL PONDS ❑ ?.: I hereby certify that I have prepared this application and that the work will.be done in ae.rtrdance with San Joaquin county ordinances.svhta hors,and rules and regOations o'the San Joaquin Local Health District. f. Home owner or licensed agent's signature cenirms the following:"I certify that in the performance of the work for which thls permit Is hatred,1 shsn not employ any person in such manner as to become subject tC workmen's Compensation tows of California."Contractoes hiring or sub-contracting signature certifies the following:"I cartity that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's comperhaa- ; tion laws of California." ; The applicant must call fore I required inspections.Complete drawing on reverse aide. ?, Signed XQ -Olt-ITte: Date- FOR 6EPARTMENT USE ONLY Application Accepted by 7 Q / ] Date Pit a Grout Inspeceion L+> �� Dato� Final Inspection by Dns 7 Additional Comments: t- , n7. ' ❑ Stk 468-678? ❑Lodi 309-3621 UMenteca 823 104 ❑Tracy Applicant-Return all copies to:Environmental Health PermitlSer.4cea 19DI E.Hazelton Ave.,P.O.Box 2009, Stk.,CA 96201 j` ICK A NW AMOUNT DUE AMOUNT RTTED EMICASH RECErVEO BY DATE PERMIT'NO. . EN 13-24 IaEV.1197) ' tM 14-n J i