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APPLICATION FOR PERMIT Noy t� Y` /// SAN JOAQUIN LOCAL HEALTH DISTRICT ' y 1601 E. HAZEL T ON AVE., STOCKTON, CA j�-��-r-3 Lf 3 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t� ,5fa � (Complete in Triplicate) A41 cP''7 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. T11is 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 2155 S. B striap_t 1-7 13 3079 LOO [itStnrlrtnn Lot Size PM Owner's Name I arry nnrn AsporiteS Ad1 5550 WilshireWT 1 shT re Blvd— Inc Annal ac Phone i y /�j�_ T NFv� ` Contractor / / ' � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS g y r 'V 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 " i [1 Public ❑ Other [A Delta Depth of Grout Seal Type of Grout—.--- I rout __I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction IX Well Diameter Sealing Material (top 50') 11^ fl,!'�1_ celk_ �oll Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 XEPAIR!ADDITION I I DESTRUCT N f- (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg apacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WellFoundatio Property Line LEACHING LINE ❑ No. & Length of lines at length/size FILTER BED ❑ Distance to nearest: Wel Foundation roperty Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Lin 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call I required i s tions. Complete drawing on reverse side. 7d L) President 3/21/88 Signed'3C'" Title: 3 FOR DEPARTMENT USE ONLY Date: Applicaion Accepted by Date - Area Q Pit or Grout Inspection by Date V Final Inspection by Date_SL: a u Additional Comments: ¢ r I( oY, t` �j e_ U h ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicants-tRetur copies to: Environmental Health Per/mit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Stk., CA 95201 of V� T U li t' S'u �i C�r� �t r� Ua�_ �r iu to ap t7 ,UV-L-t 04- LOC4,1 1),("/1,-ro Inzf- INE aA�MOOU7 NT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV. `\ aLJ boo� EH 14-26 �y