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Z `I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA l Telephone (209) 466-6781 1I II PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f� (Complete in Triplicate) E ENVIRONMENTAL' HEALT1 (Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the vHR/&7p 5�fM. This application is `(made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and egulations of the Sari Joaquin Local Health District. `:J' G/2� ' ob Address 13-2, 0 w w IF� B E ll' h 1J F __.City S�D +�� A GLot Size PM . h l` 13. o W_ f_11 B/7 Phone i� 3 'Owner's Name I1 1U f i1 IQ ZGE Address C-2,9, iI.Contractor '� + 14 � Address2,6.2.Z, ifiVEm Qz) A)6_ �-F icense NoNI/44 7d Phone, 67 .TYPE OF WELL/PUMP: NEW WELL 54 WELL REPLACEMENT ❑ DESTRUCTION ❑ i+ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (;DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES2 j DISPOSAL FLD. PROP. LINE Ie7r , jk FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS I` I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ii'Industrial ^ 4N {-ford❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '❑ Domestic/Private El Gravel Pack F1 Tracy Type of Casing G � 1'44 Specifications 1'1 Public fjC Other fl Delta Depth of Grout Seal V_k��t Type of Grout 19 err. d, 41, i I' r F > � +I 1 Irrigation �-Approx`. Depth I 1 Eastern Surface Seal Installed by _ E' u BAF-si.8GFLPcc j ;Repair Work Done ❑ Type of Pump S . State Work pone i,Well Destruction ❑ Well Diameter ill-frrve_ // Sealing Material (top 501 !I Depth.O' A_fU b -K6" Filler Material (Below 501 .t _ ;'TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION [ I DESTRUCTION l I (No septic system permitted if.public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial Other N I E Number of living units: Number of bedrooms !( Character of soil to a depth of 3 feet: Water table depth j iISEPTIC TANK E] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line II LEACHING LINE ❑ No. & Length of lines Total length/size +FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I 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 11-rules and regulations of the San Joaquin Local Health District. j 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, 1 shall not q9 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,1 shall employ persons subject to workman's compensa- I�tionlaws %Iornia." it The app) ant m si al! or II re i ctions. Complete drawing on verse i Signed Title: Date: '!�""�� -__ — I! �± FOR DE ME T E ONLY `7 f ! Application Accepted by Date fIQ Pit or Grout Inspection by ` Date Final Inspection by_ Date { Additional Comments:. ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6365 E� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EEE AMOUNT DUE AMOUNT REMITTED K INFO RECEIVED BY DATE PERMIT ND. � + EH X14-24{#tEV.I/x 5f EH 1429 ��✓ E)