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5 SAN JOAQUEN LOCAL HEALTH DISTRICT i 1601 E. HAZE;.i ON AVE:,`-STOGKTON, CA Telephone (203) 466 6781 - ' _ xe x a t:-r i .f r s..w ." .�" y�r"`ha .7, -�''"` 5 {' firrF ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "r" � ` ' 71. sc 70 In. < (Complete'jn Trlpjicate? ""K l �s uf Application is hereby made to the San Joaquin focal Health District fora permit to construct and/or install the work herein descitb8d Tlfis appUcatta€,�s K '' made in compliance with San Joaquin County Ordinance No 549 for"Age or No 1862 for welllpuirlp andrthe Rules and Regu t Ofd he San Joaquin t i Local Health District. `Rt • L { - :- e 5�- .�" ray xr �.ys, i u g s� r Job Address �C 2. � i!V�'"rl�� ey City � Lot Size 4 , Owner's Name . Address, io�' Contractor Ir►f C� `'`� Address '` License No. done j TYPE OF WELL/PUMP: NEW WELL ❑ WELL:REPLACEMENT ❑ DESTRUCTION © PUMP INSTALWTION ❑ SYSTEM REPAIR ❑ OTHER ❑ air° - - .. ......_:.-....w-.. - .._ - _.....:..-.- ......e- t-.—... ._:- _ ,_y—.s._-..r _.s,,,,..., f I ok.•tlu"ta -t«p. _ _ - - . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�,w PROP -LINt= „ FOUNDATION "AGRICULTURE?WELL O PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM ARI:i4 "t CO ION SPECIFICATIONS z r 0 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia.,of We11 Casing © Domestic/Private Cl Gravel Pack cy " " Type of Casing Specifications n Public n Other n Delta Depth of Grout Seal Type,af,Grout i I Irrigation prox. Depth I.I.Eastern Surtace.Seal Installed by Repair Work Done" ❑ Type of Pump H.P. State Work Done Well Destruction` ❑ Well Diameter Sealing Meter Depth 50'} r. Depth , .Filler"Materi3t{Below-50) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l l DESTRUCTION l I (No septic system permitted if public sewer is- available s available within 200'feet.}:. _ } Installation.will serve: PApth 'dencey�/ Commercial_ Other Number of living units: Number of•bedrooms .,.;nS. Character of soil to a df 3feet: 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 O Distance to.nearest: Well Foundation Property Line V� SEEPAGE PITS i I Depth Size y" Number r SUMPS 0 Distance to nearest:: Well Foundation L Property Line DISPOSAL PONDS ❑ w..- rte^-�-,f 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 Di3trict. 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 certifies the following: "I 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'tlppiicant" ust call for all requir ins coons.,Complete drawing on.reverse sid . - Sigrd Title:: itle Date: �— FOR DEPARTMENT USE ONLY „r. . r.,.. Date Area " " Application Accepted by — „ 1'\'r-1`1 .- ' Pit or Grout Inspection by bate -Final Jnspection by' Date j Additional Comments: ;.❑ Stk 466 b`761 :. O"Lodi 369-3(121 ii C7;Manteca :;823 7104 (-DC7,Tracy6`ii5-6385 r . "r Applicant Return"all:co tea to Environmental ea IT. 1601E Hazelton Avas, O. Sox2009, Stk CA 95201 r r s r e h ' _ pp . kp ,-> s'-.__a t .,. t:i - aasz � e 3c iJ111liQUNTrDUE, AMOt1NT REM1TTEt]s ':CKi3 fiECE1VEp'BYERM17nN�' t `'' 3 Sfiw r rae '`''' _ M . �s. �. .:.� ,.>• .--:r e. .,- 'Tti'.`!; .�YLry+tj �' - r� > IN �v EH 147ti t _ __. �.-- --.. .-nr .,�,r..�....��.«-. .-.--s...r. -i•c+- tip-. .. - .r ,� -} a .a �� { .