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IV J#/PP LICAT. ION FOR PERMIT "I SAN JOA"IN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAY k ! } W A Telephone 12091 466-6781 ti^. I � PERMIT EXPIRES f'YEAR FROM DATE ISSUED (Complete in Triplicate) � (��" 16 Application is hereby made to.the San Joaquin Local Health District for a permit to construct and/or install the work herein �Xri6e5r�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 Regulations of the San Joaquin Local Health District_ �I I Iit -I1 � L� . �i A) Job Address 7 /K- City �� Lot Size PM . ``ll, lj I Owner's Name m�}n V1'A) 1040 G'0�--rAddress �/» �� Phone Contractor� SVA,'1V Address J4 It-� �I L+ License no� 4- 40 j/ / Phone TYPE OF WELL/PUMP: �� NE WELL ❑ WELL REPLACEMENT-0 DESTRUCTION ❑ V� t PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ �I \ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES !DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y ❑ Industrial ❑;Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑;Gravel Pack ❑ Tracy J Type of Casing Specifications ❑ Public f 3 Other C-1 Delta ''J Depth of Grout Seal Type of Grout I I Irrigation 11' .-Approx. Depth 11 Eastern Surface Seal Installed by p_ lM f�1 Repair Work Done Type of Pump 55.0 H.P. State Work Done �:lrf&C.r 11M01-,I� I Well Destruction ❑ Well Diameter a_- Sealing Material (top 50.1 l� .li Depth Filler Material Below 501 if TYPE OF SEPTIC WORK: NEW INSTALLATION L] REPAIR/ADDITION f_I DESTRUCTION I i Mo septic system permitted if public sewer is 11 available within 200 feet.) ' Installation will serve: Residence_ Commercial_ Other I Number of living units: l Number of bedrooms v Character of soil to a depth of 3 feet: Water table depth 4 .SEPTIC TANK ❑ "`Type/Mfg Capacity No. Compartments KG. TREATMENT PLT. ❑ Method of Disposal ;k Mistance to nearest: Well Foundation Property Line LEACHING LINE ❑ '7No. & Length of lines Total length/size I :` FILTER BED © Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I "'Depth Size Number I SUMPS_ ❑ IDistance to nearest: Well Foundation Property Line l v ..DISP05AL PONDS Q'�I�` .. - - �: :=' _ _.a:.K,.: ...-..�,.,-�.... .�, ,..t..„..„_,;.,,� I I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this per Ilit 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ parsons subject to workman's compensa } tion laws of California." . 11 The applicant must call for all.required inspections. Complete drawing on reverse side. 1i Signed XQCs/ Title: Date: t i - FOR DEPARTMENT USE ONLY Application Accepted by pate Area I Pit or Grout Inspection by 1� Date Final Inspection by I� Date Additional Comments: !l I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I� INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 14-24(REV.t i x 5f EH 14-26 �" li �� ?-7— iI