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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. If711 South SJoaquin St. Stockton 80000 sq. ft Job Address an City Lot Size I'm Sid Cooten�Cotttmunity Linen S� vices Owner's Name Address .1 W l�ashingran Blvd-a L.A. , FQ&e213-731-3132 Contractor {Il dless3663 Omec Circle ��6, Ran j�pr,s�t�-Edova., CA Phone 9166319546 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E-j o��i�l�yy,,SImEling DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROI�Q7NF- ` FOUNDATION AGRICULTURE 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public ❑ Other {1 Delta Depth of Grout Seal Type of Grout----- I rout --_I I irrigation 4AH.tApprox. Depth [ I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ J Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i I DESTRUCTION i I Wo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence Commercial— Other 0 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth [� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �+ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line /�^} LEACHING LINE ❑ No. & Length of lines Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ n ! I herby 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 Diitrict. * ..may _ •— . — 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 Q employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I_c__ertify that-in-fh'e performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." II The applicant ust i call for required inspections. Complete drawing on reverse side. Signed X Title: Date: R DEPARTMENT USE ONLY / Application Accepted by C Data ,Area Pit or Grou Inspection by top `3 Final Inspection by ate 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi, 369-3621 ❑ 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 M FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. } EH 13-24 EH14-AIREV.t/n51 � l �.