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I y 0 APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 'Telephone 1209) 466-6781 PERMIT EXPIRES 9 YEAR FROM -DATE ISSUED •.. a „ tj,. (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District fora L ,stall the work herein d made in compliance with San Joaquin County Ordinance No. 549 for sowagoeo No. 1662 forcwelf p/umpor tand the Ri11es and Regulations of hi o San Joaquin I Local Health District. "• ascribed. f th application is 1 Job Address Lot Size _ PM Owner's Name . t c��7_ Addre SS �, ��7 `%' . Phone _ Contractof��l/ii 4 1 k --.Q6 —Address 'k,—`.f }-tT�( TYPE OF WELL/PUMP:License Noc7 �o Pt NEW WL S —_ ELL ❑ ELL REPLACEMENT D DESTRUCTION O �--A TION U SYSTEM REPAIR rJ _ OTHER n /1 DISTANCE TSEWER LINES DISPOSAL FLO. PROP. LINE_ AGRICULTURE -WELL OTHER WELL__ ! P)TS/SUMPS INTENDED USE TYPE OF WELL PRO REA CONSTRUCTION SPECIFICATIONS U Industrial O Open Bottom .71 MantecaI f Well Excavati r O Domestic/ private on _ LJ Gravel pack Dia. of Well Casing — -- [-. Public O Other---Approx.D Datta "— — Specifications L7 Irrigation Depth of Grout Seal Approx. Depth n 1astorn Surface Seal Installed by= Type of Grout Repair Work Done -1 Type of Pump H.P. _ State Work Done Well Destruction L Well Diameter Sealing Material ftop 50'1 L Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INS TALLATIONREPAIR/ADD -- i (TION C DESTRUCTION G (No septic system permitted if public sewer is Installation will serve: Residence 1 available within 200 feet:) r Commercial Other p g Number of living units: _�C Number of Brooms Character of soil to', depth of 3 -feet: / SEPTIC TANK Irk Typa/jVlfgy p'd —_Water table depth ,3,S7 —_ PKG. TREATMENT PLT. (1 r' —Capacity � �.No. Compartments —a-- Distance to nearesst: 1 Well Method of Disposal .t _._ --• _ (r f Foundation —_ Property Line, LEACHING LINEr o. & Length�of Ii es v __C FILTER BED_ Total length/size--. O Distance to nearest: Well Foundation l' Property Line �— _ SEEPA>sE'PI'LS .,� Dopth _ C _Size ' SUMPS r-- Number n Distance to nearest: Well — i Foundation _ — t . DISPOSAL PONDS D — — Property Line L I hereby certify that t have preparoo this application -arid that the work will be done in accordance with San Joaquin county -ordinances, slate laws, and rules and regulations of the San Joaquin Local Health District. Flame o Ger or licensed-ogenf;s. signature -certifies -the -following : "I certify that in the performance of the work for which this per'! -nit is issued, I shall not employ Aly pe�sonrinrsuch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies•the-following:i"I certify that in the performance of the work for which this pormIt is issued, i shall employ persons subject to workman's compensa- tion laws of California." ! S The applicant • usl call fo II r uired inspo fioris. CorYlplete drawing on reverse sid ; tl. v cal I r Signed- — — Title: ( r — — _ — Date:..'— _ POR DEPARTMENT USE ONLY Application Accepted by F ♦41 R — R --- --- ✓— --t - — Date �Qa �Q Area;—. Pit (it Grout Inspectiontby-l� _ _ Date __, " 7 —__ Final Inspection by ��[[�� 1 Data Additional Comments: _ `� / { — Cfik--$771 - 'L`( Lodi "369 3621 �_� tAantaca 823-7104 " Cf Tracy --- Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' •.- FEE .. —_..._ .�--- - • -- - ^-•- -- ....._ r___...._�.,..:. INFO AMOUNT DUE AMOUNT REMITTED CK ir CASH r T RECEIVED BY J DATE 1 PERMtI'NO 1 � Elf 13-24 InEV. I i �i , ! Q • ULJ EH 14.29178 4-.1