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/5/ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL FfEALTH DISTRICT ?� 1601 E. IIA7_ELTON AVE., STOCKTON, CA 1N ' Telephone (209) 466-6781 . PERMIT EXF'IRES_1 YEAR FROM DATE ISSUED — - (4;qmplete in Triplicate) Application is hereby made to the San Joaquin Local Healtistric-t for a peIrmit t i construct and/or install the work herein described.This application is nada in compliance with San Joaquin County Ordinance Nh.\549yfdr sew0e/Orr!Z ..)f8 2 fflc well/pump and the Rules and Regulations of the San Joaquin local Health District. Sc fJ /, Job Address _ d Lc] v�`_—_ _____---_____ City� _Non Lot Size 6 PM _ Owner's Name —Zb R.__ _fish-It�'�Q- -- Address _-- --.S /�--e._-- Phone Contractor ._✓�,IG<— _ P1�_� c/ _Address_ Q Q t�t�X �6 License NO.C904 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cf---- - - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION — At3HMULYUMt3 WdLL EIPHEFt WILL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 1 Industrial U Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing I I Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications f'i Public 1--1 Other F1 Delta Depth of Grout Seal Type of Grout _.- I I Irrrtlarion Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump _ H.P. — State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth —� Filler Material (Below 50'1 __ - i4% �. i5€L1��v��1�4►iiC)i� � iii i�;fi ��i�iiti`i�3iu'I � i��sj�iESi:�i�'6i i 1 (�i�i"s�r�c's��fi Sbfilf`�I��'"'�EWei��..._- ,_ t r G available within 200 feet.) Installation will serve: Residence L- Commercial_ Other __— Number of living units: _-_. Number of bedrooms q _ Character of soil to a depth of 3 feet: -_ _(�� C46ii y -Water table depth SEPTIC TANK Type/Mfg P4-LL {I 'l,1f_ty Capacity ((p4 IS No. Compartments PKG. TREATMENT Pt T. I 1 f j Method of Dispisal Distance to nearest: Well _A _, Foundation —L Property Line —.160_.__ LEACHING LINE f,<No. 8 Length of lines Total length/size FILTER BED I l Distance to nearest': Well Foundation__— Property Line_U50_. SEEPAGE PITS Depth __Size Number _ SUMPS I I Distance to nearest: Well -1� 9 - Foundation —_!aD Property Line DISPOSAL PONDS I I 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 Di$trict. 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 mariner as to become subject to workman's compensation laws of Califomia,"Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thisermit is issued,I shall employ r P y persons subject to workman's compensa- tion laws of California." The applicant must call f r all require 'nspections. Complete drawing on reverse side. signed X_.__ _ Title: '� Iy�.t�f Date- - �X�011 DEPARTMENT USE ONLY Application Accepted by Date�O � ree �• Pit or Grout Inspection b Date Final Inspection by a /�/� Date — Additional Comments: As _. 1-1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 .0 Tracy 13358385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE t>ERMIT'N0. . r�, 11 ,(Pr I/ 10