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Y* APPLICATION FOR.PERMIT SAN .IOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL.TON AV�.;' STQCKTON, CA Telephone (209E1 466-6781 PERMIT EXPIRES TYEAR PROM DATE ISSUED I wilt. I it (Complete in Triplicate) { Application is he,eby made to the San Joaquin Local Health ibed.This application District for a permit to construct and/or install the work herein descrf the San Joaquin is i made in compliance with San Joaquin County Ordinance No.549 for savage or ISN 1862 far weltlpump and the Rules and Regulations o Local Health District. Job Address �Z� 11J�5 LpGI�TV `I ''� City OCC Lot Size _ PM I 3� - 3�rf I�`av�lLf.-�GCa' �t �� Address 2 .� I..aS.�• �„p�t � r�hone ZD Owner's Name G� L N ; ,, �� q 0-otvz� Contractor S eC IOfA�cv1 Address ?�2-1 - M r�(q _ License No.Gl`�Ii1a PhoneTYPE OF WELLIPUMP: NEW WELL I WELL REP, EMENT ❑ DESTRLJCTlON'❑ s SYSTEM REPAIR ❑ -OTHER!❑ PUMP INSTALLATION ❑ „ DISTANCE TO NEAREST: SEPTIC TANK DISPOSAL FLD. POOP SEWER LINES . LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �rt . r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTI RUCTION SPECIFICATIONS ;Z,r Dia:of Well Casing El Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation i, Type of Casing INC— Specifications ❑ DomesticIPrivate Gravel Pack ❑ Tracy 9 �q y� r Type of Grout 1 ❑ Public n Over Fl Delta Depth of Grout Seal - I I Irrigation 5� Approx. Depth I I Eastern Surface Seal Installed by ►3A ' F Repair Work Done ❑ Type of Pump _ -. H.P. State Work Done Wel! Destruction ❑ Well Diameter -X Sealing Material'{top 501 Ytl o rl WC(I Debth 55' . ' Filler Material (Below 50') i TYPE OF SEPT4t WORK: NEW INSTALLATION l] REPAIR/ADDITION I I DESTRUCTION I I INo 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 sail to a depth of 3 feet: Water[abli depth SEPTIC TANK ❑ Type/Mfg C_apacity No. Compartments PKG. TREATMENT PLT.❑ Method g �i6po5i�' ,'.I r r-^ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size a' FILTER BED ❑ Distance to nearest: Well Foundation Property Line T �E SEEPAGE PITS t I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ ' I hereby certify that I have prepared this application and that the work will be done in accordance with San. oaquin'ctiunty ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di1trict. is 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 cartifies the wing:-I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa. e tion la of Calif rnia." The applica ust Cali f all r ired inspections. Complete drawing on reverse side. } Signed Title: �'^c eo a sf CD2 ;oata: ..� 04 1, - y, o� FOR DEPARTMENT USE ONLY t Application Accepted by - Date r Area Pit or Grout Inspection by i ` Final Inspection by Da[Additional Comments: D IC})' l 1'tkA 2 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7 !0-Tracy 8354385 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 CASH RECEIVED BY DATE PERMIT•NO.' INFO ..EH13.24(REY.,,r<51 16�-� X 9 23 4 W1�'Y1 i• 11 .93 R3- W3 EH 1428 - - -