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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j r 1601 ,E.,HAZELTON AVE:, STOCKTON;,CA-- Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED f((J (Complete in Triplicate) i Application is heiehy 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. L Job Address f� PEFIZ l II'Al6f AVS City 4 oc-I- 1 af"I .Lot Size PM Owner's NameEA01V COR'POT (154- Address 1200 St, X320-15- ¢(ausion/ Phone7Lr`T13 656-77P i� t g4S-10 Contractor W1 V}-J/ 16—' F3lrbt- 0AlL _W.Address 110.9 1-4tJPii1)StA0 NC°A9 License No. 4632L130 Phone 15 (4,---6613 TYPE OF WELL/PUMP: Nt'EWl WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ II� k PUMP INSTALLATION O SYSTEM REPAIR ElOTHER�1 /*`I•^� Cr� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z5' GG DISPOSAL FLO. — PROP. LINE - . FOUNDATION AGRICULTURE WELL OTHER WELL 1Q `PITS/SUMPS INTENDED USE TYPE OF WELL t -PROBLEM AREA'S CONSTRUCTION SPECIFICATIONS ---- i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well EZ Vatlor !V ~ -tet -2, l� Dia. of Well Casing ❑ Domestic/Private- JK Gravel Pack ❑ Tracy - Type of Casing- SVC Specifications '-Loi 0-021D P P4t.bfic l� Other C7 Delta Depth of Grout Seal S0 Type of Grout C- _ [=N f A�oNt'�t32r�nfG r 7 J Irngatian TJ Q._Approx:Depth I5k Eastern M Surface Seal Installed by�V t L c 1 f ACL '�✓�t l,lir'N4 wc-• _ Re air Work Done ❑ T p€ p Type of Pum H.P. State Work.Done _ I Well Destruction ❑ Well Diameters Sealing Material Itop 50'I f Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK:- NEW INSTALLATION 1 ) -REPAIR/ADDITION I 1 .=DE TRUCTION l ),(No septic system permitted if public sewer is } 4 ## available within 200 feet.), Installation will serve: .Residence "1p Commercial'_ `Other - Number of living units: Number of bedrooms 9l Character of soil to a depth of 3 feet:'f _ r Water table depth SEPTIC TANK ❑ 9 Type/MfgF '' "'Capacity - No. Compartments ; PKG. TREATMENT PLT. ❑ _ ,. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED EJ Distance to:nearest: Well Foundation i Property Line I SEEPAGE PITS l I Depth Size Number �? SUMPS ❑ Distance to nearest: WellFoundation Property Line - N . DISPOSAL PONDS -- ❑ > _ l I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws�6gpd rules and regulations of the San Joaquin Local Health District. ,��1 F 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 1 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 ca I requiredoiinnspe 1 o late d wing on reverse side. - Signed X / Y9 o 6l'�GD G,Jir Date:`z .J C• f cm 0 /4V")I7F��EVAe' TMENrT6'4EONLY f Application Accepted by Date p ' Area V�( ` /A r � Pit or Grout Inspection bye Date Final Inspection by Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 ,.1 FEE i INFO AMOUNT DUE r AMOUNT REMITTED CASE#K 49 RECEIVED BY DATE PERMIT N0. + EH 13-24IREV.ii..5) C� EH 14-28 / . mi ^Y