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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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.J Job Address `I 44 NL)f rh PER SIj l 1UC? AVEN O I: City STOGKf OA/ Lot-Size © 5 PM �a2(on LtilxnTy VISI} Addressl200 ShiTN ST¢EF_ NoaSTONPTA phone 713 6567755 Owner's Name .�— Contractor xylLHACr6l21'#.LrN(rIP Addressl67h RISwN IZ3 . 60HCC4r7?icenseNo.4t37310 Phone 4fs685-6613 TYPE OF WELL/PUMP: NEW WELL'S WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 50 DISPOSAL FLO. PROP. LINE 10 TV FOUNDATION AGRICULTURE WELL OTHER WELLSec F' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10. LS n Dia. of Well Casing ❑ Domestic/Private KGravel Pack ❑ Tracy Type of Casing PVC --4 bi Specifications 1-1 �-y S`L'.4o f"1 Public Other DeDelta Depth of Grout Seal Q.O fe r Type of Grout GPH�M1– t3� 1� 1�I QatApprox. Depth I I Eastern Surface Seal Installed by 30.1 LL.EfC _ ReDau Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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." The applicant call for al required inspections. Complete rowing on reverse side. � - o tleey to �' , 0 8 199 SignedX I Title: "t 1f�� Date: FOR DEPARTMENT USE ONLY 7 Application Accepted by Date � y a Area Pit or rou Inspection byl� Date -!5"/C7• Final Inspection by .vt> Dat o t Additional Com ?t L] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7106 ❑ Tricy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. INFO EH 13-24 IREY.1/x51 EH 1429