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)�f APPLICATION FOR PERMIT c rf SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEISSUED (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District"�_, ,.,xrr.` .,i' .. .r-' r.�'->. . ,- .• =fit .k ,,.. � STOCKTON fi Job Address - / City Lot Size PM Owner's Name ROSE TAV EJJjA _ Address @) t r ORWO ` .. _ Phone 464-4969 Contractor JI.Fi TT PLBG. Cof AddressIQ35 AURORA ST. License No. 202228 Phone 463-1706 r S�- TYPE OF WELL/PUMP: ; [NEW,WELL ❑ + 'WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR ES SEPTIC TANK SEWER LINES DISPOSAL FLD FOUNDA AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF�WELL• PROBLE NSTRUCTION SPECIFICATIONS ❑ Industrial fl Open Bottom anteca Dia. of- cairation _ � � Dia. of Well Casing s ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing Specifications O ❑ Public ❑ O ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation , _, �Approx.�Depth ..O-Eastern- -Surface-Seal~Installed-by- ------r--- -_ - — Repair Work Do ❑ Type of Pump H.P. State Work Done_ Well Des - coon , ❑ Well Diameter Sealing Material Itop 50'1 Depth Fillef Material (Below'50')'- - f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is � I �.l available within 200 feet.) J}` Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: P I � Water table depth k SEPTIC TANK ❑ Type/Mfg r yC T a_pq§#y L No!Compartments r PKG. TREATMENT PLT. El ' am-r Yl .- Method of Disposal Distance to nearest: Well r Foundation Property Line 1 Fou i LEACHING LINE ❑ No. & Length of lines > i'' Total length/size' F FILTER BED ❑ Distance to nearest: Well Fo&ndati n) 'Property Line SEEPAGE PITS ❑ Depth Size Number ^' SUMPS ❑ Distance to nearest: Well Foundation 4roperty.Line . DISPOSAL PONDS ❑ I r 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 I 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, I shall employ persons subject to workman's compensa- tion laws of California." , The applicant ust call f r all requirs. Complete drawing on reverse side. f7 Signed X ins ionTitle: PRE81DENT Date: 4/15/87 FOR DEPARTMENT USE ONLY Application Accepted by Date" Area Pit or Grout Inspection by } Date Fi Inspection by Date IF— Additional +Additional Comments: F ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca .823-7104. ❑.T cy 835-6385 Applicant- Return all copies.to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 FEE INFO " ANIOU�NT''.D.nUE AMOUNT REMITTED CK RECEIVED BY ' DATE PERMIT NO. + EH 13-24(FIEV. 5) EH 14-28 • VV