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20 r k vT g �:W -i `� APPLICATION FOR PCRMIT r SAN JOAQUIN LOCAL. HEALTH DISTRICT #` .y 1543 E. HfAZELTON AVE., STO:.KTON, CA acv•. Telephone (249) 46&E781 Nr�'3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iCornplate in Triplica`e) '' rm Applicati-in is hereby ma]e to the San Joaquin Local Health District for a Permit to construct andlor install the work herein described.This sPP(ieatOn rs made in compliance with Can Joaqu;n County Ordinance No,549 for scwaUe or No.1657 for welt/pump and the Rules and Regulations of the San Joaquin Local Health District- 7 iDL �i�1l >rrt 4 - city C afUr+ Lot Sizey�)e 32� PM f Job,Address -- - - -- -- i Address _-� -- Phone 3 9--7-5-7.77 Owner's Nome i �---- a5t x�s� Address_ License No. Phone T ~ b TYPE OF WELLlPU11P_ NEW WELL ❑ WELL REPLACEMENT LD DESTRUCTION ❑ s PUMP INSTALLATION C SYSTEA7 REPAIR 0 OTHER ❑ > 1 _� DISTANCE TO NSA?EST: SEPTIC TANK -_ ..— SE4v5R LINES _ DISPOSAL-FLD.___—_ PROP.LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITSISU!tf.S — >"„ Y `' INTENDED USE TYPE OF WELL PROBLEMAAEA CONSTRUCTION SPECIFICATIONS i MT4 t* " C, Industria! .7 Open Bottom Mant-a Dia.of YJeit Fxeavat"eon _ Dia-of Well Casing L•I Damestic,`Private ❑ Gravel Pack C Tracy Type of Casing Specifications y = u Public ❑Other r, Delta Depth of Grout Seal Type of Grout -fir..St�,7•yr ,iK,ff�2 �?,}frk � Irrigation ---Approx.Cry;h �=+ Eastern Surface Seat lnstalied by . Repair Work gone 0 Type cr Pump H.P. State Work Done ,., - .., b�- Well Cesiruct:on _. Weil Diameter Seali:sg t4latcrial atop 50') Depth Filler Material(Below 5G1 fYPE OF SEPTIC WORK: NEW INSTALLATION a REPAIRlADDITIOtJ❑ DESTRUCTION v (No septic system permitted if oubtic sewer s sticbk, P. available within 200 feet.) C,\ Installation will serve. Residence Commercial_ Other NumSer of living units: Plumber of bedrooms r a � —Water table depth -70 Cha•acter of soil to a depth of 3.cot: � . — Capacirl_�D - No.ComGartments 4 SEPTIC TANK 1-J Type/Mlg _ r Method of Disposal ;+ PKG.TREATMENT PLT. f r\ -_w - Distance tc nearest: Well��_ Foundation Property Line/90 -� 4 LEACHING 1.1,NF No.& Length of tines �� 'oral long'::;sire FSLTER BED Distance to neares:� WeIE�_� Foundation./n _ Property Line 30 _ Al SEEPAGE PITS C. Depth __ __Size -- Numbor _ SUMPS ❑ Distan':e to n,erv•st VVell—T_ Foundation Property Line DISPOSAL PONDS ❑ --- n n rainances state laws,a d _ n win cow o have prepared then apple3t on and that the v,ork will i e done in accorlance wits,5a Joaquin >y I hereby certify that I p p lY Tares and regulations of the San Joagwr:Local F',;afthhe following: .. - ' - Signature certifies the fo•lawin :'Y certify[haI in:he perforn,ance of the work for which this permit is issued,f spar]no-, Home owner or licensed agent's s gn t 4 'nom• empiny eny cErson in such manner as to become subject to workmai s compensarion laws of California.-Contracbfs hiring or sub-contracting signature certiiws the following:"I cer,•rfy that in the performance of the work for which this%,C..I is issued.1 shall employ persons subject to workman's compensa tion laws of :*�,•'i_r;„�m•gr r California." srSr 3 d The applicant must call for all required inspections.ns. Con i Ieredr rrin an rebe- Signed � _ Tide: Date: t" FOR DEPARTMENT USE ONLY fy ' Date Area V A Accepted ccepted by s n1�n D-'Ie Final Inspect on by Pit or Grout tnspection by �it;onal Comments: Ad y d � C,S*k -.66-67!71 ❑Lodi 369-3621 ❑ Mantes 873-7104 ❑Tracy 83S-6285 Applicant• Return all copies to:Environmental Hsaltn permit/Services 1691 E. Hazelton Ave., P.O. Boz 2009,Stk-, CA 9524t ri�.. FEE AMOUNT DUE A!_'OUNT REMITTED CASH RECEIVED BY DATE PEAMIT'NO- : n INFO u ,. t/� F/may t� k.?•'::n?it +M.e- Er 13,24 i4EV.r �5• "�4` Qp C \��~ ! `>/ .l` C{ Em ti:3 r "F �. � •� ��, .� lir$=3 �',��ri