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A ` "st"eP e.� p APPLICATIO4,FOR PERMIT ' y --SAN JOAQUIN LOCA['HEALTH DISTRICT 1601 E. H.AZELTON AVE:, STOCKTON, CA uW: Telephone 1209) 466 6781 ,- _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED e dtfr�s'bf (Complete lnTriplicate) ^ t � Application is hereby made to the San Joaquin Local Health District for a to construct and/or Install the work herein detcribelL, application N -fI 4iiadiTin edmdiarice ivith son Joaquin County Ordinance No.549 for sewag -No:1862 for well/Pump and the R51es and ReWA tions,of th)+Son Joaquin Local Health Disu*%,f# 17 ,r. r • , r City Job Address phone 3,,1 - ra Name ontractof y .Address Y`License No._ mo TYPE OF WELL/PUMP: NEW WELL ❑ _1 WELL 'CEMENT ❑ DESTRUCT" ❑ PUMP INSTALLATION ❑ ---S REPAIR 0 OTHSJ ❑ -t4 ri Y-p DISTANCE TO NEAREST: SEPTIC TANK SEWER pi `Dk�SPOSAC FLO. } PROP IJ'E_1 FOUNDATION AGRICULTURE `Yk=•'" I' OTHER WELL-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO STRUCTION SPECIFICATIONS r j `...-17`NWItsVlel - -7❑Open BotCom 9 MeI ' r 'Dia tN'Wall'Fxcavatidn ---�--�"�I 'IN'WeM Closing - r Q Domestic/Private ❑Gravel Peds Q Tracy Ty , Casing r•..� ^,, a .. r 0 Public ❑ Other ❑ Oaks De .,-,of Grout Seal Type of out ❑ Irrigation tan - ---Approx. Depth IiEastem Su Seal Installed;by Repair Work Done Q Type of Pump; H.P. s 5 _ Stats Work Done `^ _ Well Destruction ❑ Well Diameter, Sealing Mate- -stop 50'1 k Depth -:- ._,. Rier Material ow SO'1 - _ _ _ .-'•,. �_,,,. -.G.. TYPE OF SEPTIC WORK;,.NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑_INo septic system permitted k.puw server a available within 200 feet.) Installation will serve: R Idence�,. Commercial—,, ommerciat�Other Uound:adon Number of 5ving un r Numbs /Character of 5011 to a th of 3 festE;�` C` r Water.SEPTIC TANK - Type/Mfgz., � y Na:'PKG. TREATMENT PLT.❑ M Distance to ruanud: Well �� 'Property - LEACHING o.ACHING LINE1 N &.'Length If Imps. "' q;plel.bngth/Rza - -, , . . . 6 you '- "•_�--'_;w. _ FILTER BED I ❑ Distance to rrorestr Wpl' ratan Property lJna Ali SEEPAGE PITS d Depth' - Size Number_ ' SUMPS - ❑- Dietsnd&tP nearest: Well J'Foundation - "---Property,Line DISPOSAL PONDS ❑ I hereby certify that I have Prepared this application and that the wo 1 be done in accordance with San Joaquin.county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 Home owner or licensed agent's signature certifies the following: "I.ceV .that in the performance of the work for which glia penNt It Issued,i shall not employ any parson in such mariner as to become subject to workmalft compensation laws of California.•Contractors hiring or subcontracting signature certifies the foliowrng "I cartnh/that in the,,pe,formance of the work:for Which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant m at call for ail require ction mpleta drawing j-'ever»side.Signed itl `_]f/��,t� �!tt(. ` OR D ENT USE ONLY Application Accepted by "�7"'_ � Data: -1 < -a.. Area�`' Z/ Pit or Grout Inspection b Date Foul Inspection by DateL! ie Additional Comments- 0 Stk 466-Ml ❑ Lodi 3fD-*2) ❑ Manteca 8M-71 ❑Tracy 8354M Applicant- Return all copies to: Em4rd0 ntal Health Permh/Servioee'°- 601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE'. MOUNT bUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO //�' EH 4m