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• - _ .-. AE APPLICATION FOR PERMIT 4--or, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 14 6g,�[�2d Telephone (209) 466-6781 T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A. (Complete in Triplicate) ;v jv Applinetlam Is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de This icatio 41 made in compliance with San Joaquin County Ordinance No.649 for sawaptl or No, 18(32 for well/pump and the Rules and As � yof n Jar�r + Local Health District. y �Q'`� I qa 6 / fC aclu e� Alc' City&�+T-A Lot Size �`V PM. .tom Job Address r/',�y ,, / "> �/� 6� / f� C]Address P4 130 (y �A ,v WPhone Owner's Name � �� I Q Contractor Address.5 F1U&_P_ RI) License No.q4X4 49 Phone 37-.5'767 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO.__T_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } j7Q Industrial Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing 24:1 n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingYQl-LOC f - jF� Specifications I'1 Public 17 � r Other I I Delta Depth of Grout Seal 4 � Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed byww& aku-- to f� XLttT- Repair Work Done 1> Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 - � ' 't 4rtKi NreW IN6TALI.ATION I 1 REPAIR/ADDITION I I DESTRUCTION 1 I (No sen tic system permitted If publlo sower Is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms NX Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS I] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I 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: "1 certify that in the performance of the work for which this permit is issued, 1 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: "I certify th r the performance of the work for which this permit Is issued,I shall employ persons subject to workman's compensa- tion laws o ornia." The appli ant m s c I f al re i nspection . Complete drawing o aver-she/side. Signed X Title: Date: FOR IDEPARTMENT,USE ONLY f c Application Acce d b e Area Pit or Grout Inspection by Date Final Inspection by r Date Additional Comments e (�i{ 1�.1 Le 1 hd f 40-ALIM +a "jz .4-t-L ElStk 466-6781 Lodi A-36211 Manteca 823-7104 11 Tracy 835-6385.s VS 0 , 1 f-� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C" A 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT'NO. +� G EH 19211REV.1/p5r INFO �-y T/D /U EH 114!1 Y • r . � �