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I j APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E rHAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 2 Job Address g��q `©$r� �N City STOCY-11N Lot Size 3 7� 1 SCs_ PM I � ,1 _ Owner's Name OgS EW Ey Address E332 E, AtAl kb DALPhone 93 17a(0 Contractor jUSDR CONS-rAf aC ddress2027 601-A,,b CA.Ai} ST' 2-6- License No.!jl2%6 � Phone Y2.3 -0 S" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK,- _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION •ArGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ,❑_Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domesti _. _D_ . .Gravel Pack ❑ Tracy _ Type of Casing Specifications ❑ Public ❑ Other ODelta Depth of Grout Seal .Typpv�Grout ❑ I rigatio �pprox. Depth ❑ Eastern ti Surface Seal Installei I by Repair Work Done ❑ Type of Pump z H:P: State Work-Done Well Destruction ❑' l Well Diameterealin Material (top 50') Depth Filler Material (bellow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRAADDITION ❑ -DESTRUC ION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence A Commercial_ Other f Number of living units: Number of bedrooms 1 4 Character of soil to a depth of 3 feet} t_0 _ µ.-Water table depth SEPTIC TANK Type/Mfg Capacity 60 No. Compartments 2- PKG. TREATMENT PLT. ❑ � "f` � I Method of Disposal i• Distance to-nearest: Well �fJ Foundation Property Line LEACHING LINE No. & Lengtof lines – f /bo z I Total length/size erD� FILTER BED ❑ Distance Ito arest: Well � F'undation /16Property Line 1 SEEPAGE PITS OW Depth ( a Size Number SUMPS ❑ Distance to earest:- Well Foundation l D Property Line aO DISPOSAL PONDS r❑ T p.;. I hereby certify that,lzhave prepared-this a lication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin L ical Health District. Home owner or licensed agent's signature rtifies 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 b ome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: I certify that in the rformance of the work for which this " fy permit is rued,1 shall employ persons subject to workman's compensa- `tion laws of California." € s The app nt must call for al required,ins ctions. Complete drawing on re erse side. Signed Title: 0 Pis&fiTt003 As<I^11 GVe- Date: - -2 l FOR DEPARTMENT USE ONLY Application Accepted by ` Date 7— ' Area Pit or Grout Inspection by Date �,"�D Final Inspection by Date Additional Comments: ❑ Stk 466;6781, ❑ Lodi 3W3621 171 Manteca 823-7104 --O" rkj--835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.1/85) EH 10.28 •,�C] 1 A S \