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ww�r /1130 O APPLICATION FOR PERMIT as `0- ' ( t��9 SAN JOAQUIN LOCAL HEALTH DISTRICT I MAY 2 Q 1601 E. HAZELTON AVE., STOCKTON,, � E`11t1?: ;�:�dtE�TA�HCAl7H Telephone (209) 466-6781 �� A# Lj 2� 12 ' /SERVICES PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicat and/or install the work cation is made ntlon is compliance weteby ith made Sano the San Joaquin Joaqu n County Ordinance leNo".A549 for sewage or permitealth District for a to 1862 forcwell//pump and the Rules and herein R Regulations of the San Joaquin Local Health District. cl) . 1/lt` CGO �f`j City T62�f Lot Size in Job " PM Job Address — '"� ,�I (� / ��///,,,,,, y•�1 �+ 1POE lJ v1�lD L it//v rte —/ l� Owner's Name L- . Address ' U rR cx.v�.Co-.• l Contractor O&IIN) Irl l.(3 h�0 Y I Address C! l icense No. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER, Q�1 _ DISTANCE TO NEAREST: SEPTIC TANK S ^! 'r- SEWER LINES 7-1 DISPOSAL FLO. _D7-- ROP. LINE PITS/SUMPS/-- / .J FOUNDATION "I-1- AGRICULTURE WELI,--r OTHER WELL �C /INTENDED USE TYPE OF WELL PROBLEM AREA _. CONSTRUCTION SPECIFICATIONS 1! `Y d . of Well Casing Industrial •� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I ` 9 ❑ Domestic/Private [P-Gravel Pack wfracy Type of Casing �r sv�„d{! y�f- /$�lap�`eod�ions 1'1 Public ❑ Other fl Delta Depth of Grout Seal _ Type of Gtrout' mp I I Irrigation Approx. Depth �I II Eastern Surface S al Installed—by >"^ - IZZ Repair Work Done ❑ Type of Pump Lm�J H.P._1--� State Work Done_ Well Destruction ❑ Well Diameter PN Sealing Material (top�) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I availaeptic systhin m fitted if public sewer is le Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms - C� \ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS ❑ 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 D3trict. 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 became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California" The applicantt call for all l@\cared ins to s. Complete drawing on-�`�rse side. Signed X /titi 4^ `� Title: S Date: FOR DEPARTMENT USE ONLY /© Application Accepted by Date Area Pit or Grout I spection by a e M Final Inspection by Date 2 v Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Mant ca 823-7104 ❑ Tracy 835.6385 Applicant- Return all c fes to: Envi�p�mental Health Permit/Sery es 1601 E. Hazelton A e., P.O. Box 2009, Stk., CA 9520 �/57�a- EE AMOUNT DUE AMOUNT REMITTED flECEIVED BY DATE PERMIT•NO. INFO CASH �..EH 13-]a(REV.V x 5) oj • od ps.Uc7 Its(ay ta �3$1 -a�a► EH 14Za