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li r I! .� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ p 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED li (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. I� Job Address 700 (A)EYE WLASH,I-X Q City S"S0C4'r0U Lot Size 2-06 X Soo 1 PM f Ow!l er's Name I Address lOs�' L+.F.T 7: kk!Z LA. CA Phone Z 13-'18-162W Contractor L�1YA/E PPZAIC.Address Zls._& -n4, f K0808 k��ClOicenseNo. S10011 Phone9/6462.-Z6Z57_ TYPE OF WELL/PUMP: NEW WELL,K WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1VA SEWER LINES >100 DISPOSAL FLD. PROP. LINE l FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS i :?INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y If ff F1 industrial industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation rr Dia. of Well Casingis ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC._+ 5t EEL Specifications l"l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Comlag/esm 1`(, i I Irrigation __.Approx. Depth l I Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump H.P. /4/,oq State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 ". Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION l I DESTRUCTION I 1 INo 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: SI QTS A-10t, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 4 PKG. TREATMENT PLT. ❑ Method of Disposal ii Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. R Length of lines NA- Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line IT SEEPAGE PITS { I Depth Size Nh Number a SUMPS ❑ Distance to nearest: 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." '1' The applicant must call for ail required inspections. Complete drawing on reverse side. _. SigI cL.--.---.-_ Date:Signed XTitle: Z` y 41 lGay„!ar-L Ids F01 EPART USE LY Application Accepted by Date - II �T Pit or Grout Inspection by Data Final Inspection by Data ii Additional Comments: 01!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 . q _ I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATA? P_ERfrIT'NO. �+ INFO CASH +.EH13-24iREY.r/Nsr Y`rl• Yf 3 , �Z ��v �Z EH 1426 C� f