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APPLICATION FOR:PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON-AVE., STOCKTON, CA ;. Telephone (209) 461 PERMIT EXPIRES:1 YEAR FROM DATE ISSUED {Comp.fete in Triplicate) y ` ''" - Ordinance No.549 for sewage or No. 1862 for well and the Rules and,Regulations of the San Joa in Application is hereby made to the San JoaquinLocalHealth District for a permit to construct and/or install the LoOrkthereO�ir�described.R ��application T�ti�2 s made in compliance with San Joaquin County , h Local Health District. 'Stockton PM 821 W Sth — �: � .. ' ._ �,City--_---- Lot Size—��—.. _ y' Job Address _ 463•-5813 _ Tom Oliva - 31.9 W 4th Phone Address — Owner's Name 462-5597 �. Clank Well 3?156f1 - - _ Phone., . „License bio.._ .-- Con�ractor's Names WELL REPLACEMENT ® DESTRUCTION ❑ NEW WELL ❑ OTHER ❑ TYPE:OF WELL/PUMP: SYSTEM REPAIR ❑ i PUMP INSTALLATION ,I �f DISPOSAL fLD. PROP. LINE `L k. I SEWER LINES — D1ST.'ANCE TO NEAREST: SEPTIC.TANK OTHER WELL PITS/SUMPS FOUNDATION -- AGRICULTURE WELL } { tt INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS It Dia. of Well Casi 8 5/S Dia. of Well Excavation I ? 10 ❑ Industrial ❑ Open 9ottom ❑ Manteca Type of Casing steel Specifications ❑ Domestic/Private Gravel Pack EJ Tracy Typrof rout other ❑ Delta Depth of Grout Seal, ❑ Public Surface Seal Installed by - �gpprox. Depth ❑ Eastern to Work Done L IL Irrigation Sta A g , Repair Work Done ❑ Type of Pumpy Sealing Material )top 501 i r Well Destruction ❑ Well Diameter Filler Material {Below 50'} Depth er is available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ TION ❑ DESTRUCTION ❑ available,septic system permitted if.-public sew fr installation will serve: Residence Commercial_ Other c, { ; Number of livingjunits: Number of bedrooms � ��! �1 I�td 1'04'�Water table depth ' Character of.soilao a depth of 3 feet: Capacity— No. Compartments r s SEPTIC TANK. f "# � ''Type/Mfg Method of Disposal s PKG. TREATMENT PLT. ❑i" . _ ' ' Foundation — Property Line , �. Distance to nearest• Well _ Total length/size i LEACHING LINE ❑ "l No" & Length of lines Property Line� 04 — �. Foundation—�— FILTEfl BED ❑ Distance to nearest: Well I ` k .Size Number l SEEPAGE PITS ❑ Depth Property Line ❑ Distance to nearest: We11 Foundation -� I SUMPS ' DISPOSAL PONDS: ❑ �..r Y � I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin xqunty'ordinances, state laws, an rules and regulatioriB.of-the-San Joaquin Local Health District. -! certify that in the performance of the work for which this permit is issued, I shall not I Home owner or licensed agent's signature certifies the following: " employ any person in such s to:become subject to workman's compensation laws of California." Contractor's hiring orsub4ork ac's signature certifies my person in:"l c ify that a ormance of the work for which this permit is issued,1 shall employ fpersons subject to workman's compensa tion laws'of}California." , ; 1 ' ,.1 i ns Com ate drawing on reverse side. r The appiicarl ca r i € i Date: - Title: VP € 5igned FOR DEPARTMENT USE ONLY '� ► s i « Date Are Application-Accepted by i_ _ _ ; .—�-- w.^ti" `. Date T } Final'Inspectronsby°.�' Date Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 7104 ❑ Tracy ` /�r� � Applicant Return a1lcopies toaEnvironmentaP;Health,Permit""/Ser'vii es 1601 E. Hazelton Ave:, P.Q. Box20fi9;StfC.;CA 95201 r '�''' �'` k' ' RECEIVED BY DATE" PERMIT'NO. . IFEE —AMOUNT DUE `` �AMOUNT,REMITTED CASH �,.,� r INFO,:, `. - �,� -+ � � r•�� ' ; ,t�. - Fs5�SSy '� i + EH 13-24(REV.10183) ` .;�, EH 1428