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} APPLICATION FOR PERMIT � - SAN JOAQUIN LOCAL HEALTH DISTRICT t -, 1601 E. HAZELTON 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. 4 Job Address Soo 1-�+ /'OVl SE fiVc City QD Lot Size -T Acr'%S PM Owner's Nam - nF &1-da Address 5,00 E L.OV/Se— Phone OY S8-S Contractor F7Geltec{1 Address "1/638 CAC Baty Street License No. HloH3ayPhone S C5 9-0 Vol TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O,T/H,�ER�MOA/I'Nlt/A/4 WALL DISTANCE TO NEAREST: SEPTIC TANK u/4_ SEWER LINES Z 00/ DISPOSAL FUD. VIA PROP. LINE IS'Q FOUNDATION Z S' AGRICULTURE WELL 1125/ OTHER WELL -Z0/ PITS/SUMPS. 60 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0,Gravel Pack ❑ Tracy Type of Casing OVG Specifications ❑ Public ❑ Other ❑ Delta Depth of Seal 3 FP Type of Grout L L t ^ W- 0 ❑ ❑ Irrigation ApprOx. Depth Eastern Surface cal nstat(ed C by ft k Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter //1 Sealing Material(top 501 Depth 20 -feet-FFiller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTA TION ❑ REPAIR/ADDITION ❑ ESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Co ercial_ Other Number of living units: _ Number of bed ms 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: Wel Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well undation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to Barest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." / /J / /N The applican must call for all required ' cti plate drawing on reverse side. Ste. Alla C OXY a p '7 Signed Title: ` p�'O/a s /c ri Date: JE FOR DEPARTMENT USE ONLY Application Acce VYI / _ / Date — /7 - 7 Area -�// Pit or Grout Inspection by ( Dete 7l-7C / Final Inspection by Date V 47 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 FEEAMONT DUE UAMOUNT REMITTED . RECEIVED BY DATE PERMIT NO. INFO . EMI}M(REV Yd .vR 5) �3S t DO nI9 CA �� D /�� 7 /J1 EM,.- JK.YL.Lt !_i 0- q' � , � _