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APPLICATION FOR PERMIT { SAN JOAO.UIN LOCAL HEALTH DISTRICT r, 1601 E. HAZE T ON AVE.,-STOCKTON, CA Telephone (209) 466-6781 }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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3355 Odell Street- city Stockton Lot'Size PM Owner's Name Tanya-R. " YOUAddress'2951 Postwood, San Jose Phone X08 95_07$ 135 ,Devries,Losi License No. Phone334-17.0 4 Contracto�al WeSt�Constr. "" 00 Address _ TYPE OF WELL/PUMP: NEW WELL r7 WELL REPLACEMENT❑- DESTRUCTION ~PUMPINSTALLATION-❑ s�- SYSTEM REPAIR= - - ---OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 1 .� ` .PITSISUMPS 0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICTI AONS T ❑ Industrial ❑ Open Bottom ❑"Manteca Dia. of Well Excavation Dia- of Well Casing mestic/Private LJ Gravel Pack U"Tracy Type of Casing Specifications rout L�Do ❑ Public El Other i=❑ Delta Depth of Grout Seal r^^ _Typeof Grout Dr C;eIllen I + 5� ❑ Irrigation ---Approx. Depth ,, ❑ Eastern Surface Seal installed by , Repair Work Done El Type of Pump H.P. State Work.Done_ f a r Well Destruction Well Diameter Sealing Material (top 50'1 *' Depth Filler Material (Below 50'1 C_ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C1 DESTRUCTION ❑ (No septic,system,permitted if public sewer is t 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 00 SEPTIC TANK ❑ Type/Mfg Capacity ,No. Compartments PKG. TREATMENT PLT. ❑ t (Method of Disposal Distance to nearest: Well Foundation Property Line (�rrr� j LEACHING LINE ❑ "rNo. & Length of lines Total length/size ~ FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS Ir ❑ Depth Size Number SUMPS 1x ❑ Distance to nearest: (Well w-"—t: Foundation Property Line DISPOSAL PONDS ❑ j I hereby certify that I have prepared this application and that the-wbrk Will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health District. r 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 to workman's-compensation laws of California."Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject 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." k i The applicant ust call for all quired i spections. Complete drawing on reverse side. Signed X Title: 10 Date: G .r FO DEPARTMENT USE ONLY Application Accepted by "" # Date Area -�S Pit or Grout Inspection by Date '' Final in by Date Additional Comments: i ElStk 466-6781 ❑ Lodi 369-3621 ElManteca 823-7104., ❑,Tracy 635-6365 Applicant Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 I t FEE �N. INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. r `` p E + EH 13-24MEV.1/a57 i�lt � n EH 14-25