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� r APPLICATION FOR PERMIT r ✓e, i SAN JOAiaUIN LOCAL HEALTH DISTRICT J 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-.6781 n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Np7 (Complete in Triplicate) 1 6 41cation is ; Application is hereby made to the San Joaquin Local Health District for a permit o. 1862 for well/pump and the Rules and Regulations of the San Joaquin construct and/or install the work herein described. This app A made in compliance with San Joaquin County Ordinance No.549 for sewage or No. Local Health District, I 344 So . Oro Ave. City StocktonLotsize 130 X 50 PM Job Address 344 S. Oro Ave. Stkn, Ca Phone 352--2605 Canrlelario Escobar Address Owner's Name psZ,oj Contractor. Address, License No._Phone TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT ElDESTRUCTION 11 SYSTEM REPAIR ❑ OTHER F3 n PUMP INSTALLATION ❑ 55 f t . DISPOSAL FLO. PROP. LINE ]h11J4 DISTANCE TO NEAREST: SEPTIC TANK - --£ 5t�-- SEWER LINES — i FOUNDATION ft- AGRICULTURE WELL OTHER WELL PITS/SUMPS IPROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL pia. of Well Casing r, Ll Open Bottom ❑ Manteca Dia. of Well Excavation 4 ❑ Industria! p Type of Casing Specifications — E Domestic/Private ❑ Gravel Pack ❑ Tracy I1 1 Delta Depth of Grout Seal Type of Grout [ QA `l Public aOther - I I Irrigation 5 t'lApprox.,Depth l 1 Eastern Surface Seal Installed by State Work Done Repair Work Done Ll Type of Pump H P Seating Material (top 561 Well Destruction ❑ Well Diameter Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I availableseptic ble wthin 200 feet.)ed if public sewer is S Installation will serve: Residence X Commercial Other Number of living units: Number of bedrooms + Water table depth Chatacter of soil to a depth of 3 feet: ❑ Type/Mg Capacity— No. Compartments Type/Mfg SEPTIC TANK Method of Disposal PKG. TREATMENT PLT. ❑ ^- Distance to nearest: Well 5 ft •Foundation Property Line 4 Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED El Distance to nearest: Well Foundation I 4 I Depth I SEEPAGE PITS Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 signature she not employ any person in such manner as to become subject to workman's compensation taws of California." Contraceo�nsrsufi suring bject to workman�scompensa- certifies the following:"'I certify that in the performance of the work for which this permit is issued, I shall'employ p 1 tion laws of California." The applicant t call for re uired ins ns. Complete drawing on reverse side. 3/1/90 Title: OWNER --Date: { Signed X ;. . FO EPARTMENT USE ONLY Date Area Application Accepted by l I$ i Mr,Fll.s . FscoLa�- c Date Final Inspection by s D Pit or Grout Inspection by i4C Gjo Additional Comments: 171 Stk 466-6781 ❑ Lodi 369-3621 0Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT NO. FEE LINT DUE AMOUNT REMITTED CASH INFO r. EV a.EH 13-24(REV.1/151 3�'0-3 p�d r t/✓ EH 14-26