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1 1 APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to the San Joaquin Local Health District for a permh to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.5e9 for usage or No. 1B62 for well/pump and the Rulas and Regulations of the San Joaquin Local Health District. �( Job Address �I "c Ccityley—dw en Lee Sim V6,41 PM Owner's Name r1Add Add/ddre�essas/ 4� �F-�� /Phone �F Contractor s✓ Address 0 1 F�1 I&CA License No.�Phone a� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE _ FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Ban= Cl Manteca Die. of Well Excavation Die.of Well Casing _ ❑ Domestic/Private Q Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public n Other IT Delta Depth of Grout Seal Type Or Grout_ I I Irrigation Approx. Depth I I Eastern Surface Saul Installed by - Repeir Work Done ❑ Type of Pump H.P. State Work Dore Wall Destruction ❑ Well Diameter. Sealing Material (top So') w Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDIMON 11 DESTRUCTION I I (No septic system permitted it public sewer is available within 200 I.IJ Insuallinum w111 serve: Res ante a"Commercial i. - Other Number of living unia: Number of b.srdrooD -s f Character of sail to a depth of 3 feet: —————--Water table depth Q -` SEPTIC TANK B1Typ,1Mfg' e-13.0 A&V IF Ca!ecity 1 Zill.2 No. Compartments 3F 1 PKG.TREATMENT PLT.❑ '^ ' Method of- Distance 1 xF ^Asa �Q / Pm' —/ to neereac Wellaoo Foundation Property Line LEACHING LINE. LU .. B Length a Iiinek r Total Nngth/s"qe ME� FILTER BED ❑ Distance tp neahm: Well a-20 f Foundation� . Property Lin SEEPAGE PITS (7 Depth 21v Sun Number SUMPS Ll Distance to nearest: Well aiSZ / Foundation 70 1 proper" Liner DISPOSAL PONDS ❑ I hereby canify that I have prepared the application and that the work will be done in accordance with San Joaquin county ordinances, state Were, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed gent's signature mrtifiss the following: "I canny,that in the parliaments of the mark for whkh this permit is issued.I shall not employ any Parson in each no nrer as to bacome subject tp workmen's compensation hove of CalNomie." Contractor's hiring or su4cannacOg signature candies the fokowing:"I canify that in the Performance of the work for which this permit is hunts,I shall employ persons subject to workmen's compensa- tion laws of California." The applicant or roll for all/yequ�yed'nspections. Complete drawing an reverse title. /+ SigPodX +�Kx/ Tiffs: 4ZJAk4 Dab: � �' ` FOR DEPARTMENT USE ONLY Q�(' r� Application Accepted by At A Deb Aran �js� \ Am[ .98' �Plt or Grout Inspection by Date Z<_ Flnel IasPosdon by Additional Comments: ❑ Stk a 6781 ❑ Lodi 389-3621 ❑ Mantes i I1237100 ❑Tracy 835i186 Applicant- Return all copies to: Environmental Heats Permh/Services 1M1 E. Haaahon Ave., P.O. B 2DD9, Stk., CA 9=1 kle FEE gMOUNT OUE AMOUNT REMITTED CK I RECEIVED 9Y DATE PERMIT NO. NFD D ] _ x EH 11N IRFy.�/xnl U e, 66 , S '8 �$ , 7 EH 14M