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- f •, I APPLICATION.FOR PERMIT ES tz SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZE T ON AVE.;ISTOCKTON, CA L1 — Telephone {2091 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED < w f Com fete in Tr' x 'i p iplicate} ,. 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 i made H compliance with San Joaquin County Ordinance No:549 far sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District: s Job Address 2005 ORWOOU STOCKTON City Lot Size - PM Phone ��'�0©O Owners Name LOUIE OSBORNO Address 2005 ORWOOh — - - Contractor��+"L`j��.P � - - Address 10 S. AURORA ST. License No. 2O� �2228 Phone 46'3-1706 TYPE OF WELL/PUMP: � NEW WELL ❑ � WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES r FOUNDATION DISPOSAL FLD. PROP, LINE - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca ' Dia. or Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. Of Well Casing ❑ Public Type of Casing Other's ------❑ Delia - - Specifications ❑ Irrigation �""Depfh;ofGrout Seal ------v �Approx. Depth ❑ Eastern Type of Grout Surface-Seal Installed by i Repair Work Done 0 Type of Pump'I j H.P. '# Well Destruction ❑ Well Diameter "� _ •y�_� State Work Done_ Sealing.MaterQ (top 50'f—1 Depth Filler Material {Belo EPTIC WORK: NEW w 50'► + `N TYPE OF SINSTALLATION ❑ REPAIR'lADDITION•❑t�111 111111-- 111. lie, DESTRUCTION11011 INonaseptic system permitted if public sewer is Installation will serve: Residence Veble within 200 feet.) ia F `— CommercO h r Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: SEPTIC TANK Type/Mfg ,' r� 's a% j Water table depth r t PKG. TREATMENT PLT. ❑ ! f,''' ` •P+ -�, �- Capacity_ I No. Compartments Distance to arest: Well -� }"I" ._-.- Method of Disposal Foundaton.,i j.; ;— Property Line ' LEACHING LINE # ❑ No. & LengtFl of likes gggi.. �`;,�� "r FILTER BED ClDistance to nearest: Well Totaf`Iength/size Foundation "Property Line_ SEEPAGE PITS >�r pepth SUMPS Size Number ❑ Distance to nearest: --Well- _-Foundation-- �—. .. DISPOSAL PONDS ❑ Property Line 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 Locaf Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this per is issued, I shall not employ any person in such manner as to becbme subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature f certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall em to tion laws of California." employ persons subject to workman's compensa- The applicant st call for all required inspections. Complete drawing on reverse side. Signed x title: PRESIDENT � i Date: 4/14/87 FOR DEPARTMENT USE ONLY Application Accepted by �— - Pit or Grout Inspection b ° Date Area Date Final Inspection.b Additional Comments: r. ., Dater ❑ Stk 466-6781 ❑ Lodi 369-3621 i ❑ 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 FEE INFO F AMOUNT DUE +*AMOUNT REMITTED RECEIVED 9Y DATE PERMIT'NO. '4 13-24(REV.s i a 5y �—�