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��. APPLICATION FOR PERMIT .. J SAN JOAQUIN LOCAL HEALTH DISTRICT �- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VOP�N� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/oV nstalltt th6iv�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 16 City JL/ � Lot Size/lo Z .3 ___%% 50,_4- 17X k Z 1 Owner's Name I Avc(F fL =t--L- Address 320 K1- J 5+.y e W Q� Phone { /D^ ;"3 _ sa�z BRE N u aN s ql6 Contractor Lo E: oso lc Address L- 7115 CA License No.-qI S3Q Phone (. 52-4(6+C) TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Tb�XR4encnle PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER )< 6t Fr�`E D DISTANCE TO NEAREST: SEPTIC TANK AIA SEWER LINES -120 DISPOSAL FLD. PROP. LINE �U FOUNDATION /O AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS XIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation JR Dia. of Well Casing _ I1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing N°h r: Specifications F1 Public 1-1 O her NeM14ar` n Delta Depth of Grout Seal FVN eY4 Type of Grout el,p/oro��'-t o JJ 1 1 Irrigation ow Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done !7 Type of Pump �_r—_ H.P. _ State rk Done El Well Destruction Well Diameter �� _�__ Sealing Material (top 501 eow / r Or U Depth 4�i Filler Material (Below 50') _._ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 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 fes/ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth Size Number SUMPS Ll Distance to nearest: Well_ Foundation _ Property Line DISPOSAL PONDS n 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 Diltrict. 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 applicapi mu;t call for all required inspections. Complete drawing on reverse side. Signed X .L h1Gfp Title: &11E,C 4 S " Q Date: " FOR DEPARTMENT USE ONLY �(11 Application Accepted by a Date to-2 1 Pit or Grout Inspection by Is.i Date�� Final Inspection by 1 V W� f .1 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 ENVIRONMENTAL HEALTH, FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ERMITY NO. EH 13.24(REV.1/M 5) �� /O_ ✓ V33 � J 1/0—;�5 L(� ((/ EH 14-28 80 pCCI