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! )f R tti APPLICATION FOR PERMIT *Vr SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F. HAZE t ON AVE., STOCKTUN, CA Telephone (209) 466-6781 { PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 1 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wull/puinp and the Holes and Reguldtions of dw San Joaquin Local Health District. Job Address 711 South San 3oacuin St. Stockton 80000 sq. ft _—_ City�_ Lot Sice Sid Cooten{Covmunfty Linen SQ `yi e�} 7 1—_313 2_ Owner shame —__ Cbt3l—� �—�nf�shin�rttlrLBlV.tl T,_Ate. F�t+Anr2 - --- - __.Contractor _ R�� n , T� dless3663 Omec Circle #6, Rangy t{}15�@,l,dova, CA- Phnn, 91663I951Fh TYPE OF WELL/PUMP: NEW WELL LJ WELL FiEPLACENILNT I 1 DLSIHUCTION I I '� — PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER F5 Roil s tripling DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF�'4{ I1n .c ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ". Industrial ❑ Open Bottom L] Manteca Dia, of Well Excavation Dia. of Well Casing ^� ❑ 0omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificmions !f'1 Public f"1 Other Cl Delta Depth of Grout Seal Type of Grout i I I Irrigation 4,Of Vgpprox. Depth l I Eastern Surface Seal Instdllod by Repair Work Done © Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material (top 501 Depth filler Material f8elow 50') TYPE OF SEPTIC WORK: NEW INSy"ALL.ATION [ I HEPAIf]/ADDI{'ION t I UE,'1RUCIION I t [No :elrtu. sys[e,n pirrnirt[ce1 it yFublic Ncwm rs avdilable within 200 ioet-f Installation will serve: Residence Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet WTte.r table depth l SEPTIC TANK ❑ T ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total len h/siz FILTER BED ❑ Distance to nearest: Well Foundation ine 1 SEEPAGE PITS I I Depth Sire Number _ {� SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work w,'l [,u clone in accordance with San Joaquin county or[Gnefices, stale laws, and .., ,rules and regulations of the San Joaquin Local Health Di§trict. '. .A Home owner or licensed agent's signature certifies the following: "i certify that in the performance of the work tot which this permit is issued, I shall not r employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or:.ub-contracting signatur4- certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ poisons subjnrt to workman's cornl+ensd- tion laws of California." The applicant ypust call for required inspectio,,s. Complete drawing on reverse side, Signed Tifln: I'` Date: � .-Z R � DEPARTIIAFNT USE ONLY �j Application Accepted by . .4 pate -2l j Ama Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: e ❑ Stk 466.6781 ❑ Lodi 359.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servicos 1601 E. Hazelton Ave., P,O. sox 2009, Stk., CA 95201 INFO FEE L AMOUNT DUE AMOUNT REMITTED CASil :{rCCiV1'r1 BY DArr PEkMIi NO. . EH 13-24(REV.1/a 51 ` EH 74•26 _`.� �� ^�' q_7'�j,�� C��'_ .-7 er