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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 4-6 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 37T4r W. AtJRoS Sr- City STK Lot Size -WX 14 `y PM Owner's Name S4 M D,4S.ALLA "Address .40'> &AY00 GT PW Ai Phone It a---.216.3 _.._. _.._.._..___._.__... _._....._. .._. :._....w.___ prat q ( n .5 f1 / –I0 Contractor Q �� Address�� lX LicenseNt � QNo. p0Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 5( PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK .Si SEWER LINES DISPOSAL FLD. /O' PROP. LINE ZS FOUNDATION 3 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta depth of Grout Seal Type of Grout r` ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ""f /101 f_, H.P. State Work Done „A Well Destruction Well Diary r a�Qr,� r Sealing Material (top 501 —mak It�T Depth Filler Material (Below 501 CFr - 6 t G'v SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is ~ available within 200 feet.) Installation will s esidence_ Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3feet: Water table depth SEPTIC TANK F0Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We11 dation- Property Line LEACHING LINE ❑ No. & Length of lines z ength/size FILTER BED ❑ Distance to nearest:, Well i Foundation'' Pr-ollamt Line SEEPAGE PITS ❑ 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 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-contracting 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." The applicant must all for rrequiged inspections. Complete drawing on r v side /yr 43, Signed 'tle: / � Date: .. FOR DEPARTMENT USE ONLY j- �� Application Accepted by Date; 2- V Area 0 / Pit or Grout Inspection Date Final Inspection by; Date �S Additional Comments: ❑ 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 FEEr INFO AMOUNT DUE A�MOUNT REMITTED CASH RECEIVED BY DATE QPERMIT'1NO. + EH 13-24(REV.1/95) 3�' �� / �a pVL.' Z' •�( O ?�Z� 1 EH 14-26