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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRESA YEAR FROM DATE ISSUED i t (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. 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. Job Address 17080 C01,BTOCE 1W City STOC'1001i Lot Size 4�) ac PM Owner's NameDAK P'IUMAS Address SATS; Phone 931-4998 � Contractor 1 ITH GxOSS Address PO BOX 173 License No. 37` 385 Phone X34--4725 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-jaJ} DESTRUCTION ❑ PUMP INSTALLATION G SYSTEM REPAIR LJ OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK 7� SEWER LINES \ DISPOSAL FLD. — -PROP. LINE, 15 \ t FOUNDATION AGRICULTUREWELL\ OTHER WE-t:45 1 1��P1TS/SUMPS _ d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONSPECIFICATIONS - OQ� ❑ Industrial ❑ Open Bottom ❑ Manteca' Dia. of Wn ExcavationYl Dia. of Well Casing 6 arch E3"Domestic/Private l#Gravel Pack ❑ Tracy Type of Casing PUC - Specifications I [7 Public Cl Other C1 Delta Depth of Grout Seal'-' S� Type of Orout't Cement _ I I Irrigation -Approx. Depth I I Eastern Surface Seal-Installed by 11uGY' -('�0 i Repair Work Done ❑ Type of Pump slab H.P. '3 State Work'Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth ' Filler Material IBelow 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION I I DESTRUCTION l I (No septic-system permitted if'public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms { Character of soil to a depth of 3 feet: 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 ❑ No. R Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line e� !ri 1 f 4 l SEEPAGE PITS I 1 Depth Size Number I sump's ,' ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ ) 1 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 District. 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-contfacting 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." ' X .,.r The applicant must call for all squired inspections. Complete drawing on reverse side. _ Signed X Title: Date: f r FOR DEPARTMENT USE ONLY Application Accepted by Date VAraa r� Pit or rou Inspection by bate Final Inspection by T i Date Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �{{{�� r. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY� DATE PERMIT'NO. INFO CASH // C //��cc c /�/y _r. +.EH13-24IRE V.riH51 ( S�-V� /D✓� Q ~�� ..�^/ r�! "- EH 14-26