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4Z,10 APPLICATION FOR PERMIT L, S JOAQUIN LOCAL HEALTH DISTRICT G�k i c f`�J-� !. 6'�U 1 1 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 ��i.hesby.,d, PE IT EXPIRES 1 YEAR FROM DATE ISSUED UI� (Complete in Triplicate) ion 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 2121.8 AyENr4 R D, City ESCAIOM Lot Size 2,0 ACRES PM Owner's Name ,� ffT (� oc ka„ Address �5�yI'17' el Phone 0? Contractor TAWLVSk � &ydl Address SD S+kA License No.,ZUR 43 Phone_ O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 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 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 (J Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: .NEW INSTALLATION ❑ REPAIR/ADDITION N DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence - Commercial_ Other Number of,living units: A- Number of bedrooms Character of soil to_a depth of 3 feet. 44A"PA A Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments- PKG. ompartments PKG. TREATMENT PLT.:❑ Mhad of Di sal f spo 1 ...-- C Distance to nearest: Well Foundation- � "'Property Line LEACHING LINE S, fib. & Length of lines Total length/size, FILTER BED ❑ Distance to nearest: �-�-ell-�- Foundation Property Line ■ Depth Size Number Z. a SUMPS ❑ Distance to nearest: .. Well-/,O- Aa= Foundation OO Property Line/ Ob DISPOSAL PONDS ❑ I hereby certify that I have�p epared this-application and that the work will be done in accordance1.avith San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. .0 _- Home owner or licensed agent's signature certifies the following: "I c�rtify 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'p compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work f6i which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." Th g applicant must call for,all required inspections. Com late drawing on reverse side. 3-��Q- Signed X Title: Date: �_ 8(4 FOR DE14RTMENT USE ONLY Q/ ►�(\� � Y�AA-N Application A'cceptedby 1C.A, �hA� o»,,.o.,..,,� Date -a 15(p Area L . Pit�or Grout Inspection by Date Final Inspection by y% - Date ?- v Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.., :O Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24(REV.I/n al EH 14-26