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l Iq 0*1� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT /Y\Lo A\ �� �� X55 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 f 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_CounttyOrdinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �� &UIJ �jrtrq�,rj• 'Y I dao G-1-�w c .x J_..-d 4`0 0� Q r j. ni, GO-5) Job Address �rI'� � City Lat Size ' PM P1 a,460% 190 l�aAtf C f� Owner's Name KAYO t! 1 I C�� i Address 909 S � rOtfx � Phone C� �P Fria p#7 49 Contractor GSC-fLC Z" G Addres � �!'ws_A o5 , IYO&License No. Phnne(l/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION P9 {Aitvr}err PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE +` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 17 Other C) Delta Depth of Grout Seal Type of Grout I I Irrigation A ! g" —.-Approx. Depth I 1 Eastern Surface Seal Installed by l Repair Work Done D T r P Type of Pump H,P, State Work Done Well Destruction Well Diameter Sealing Material {top 50') C_em 0,OT —10 — Depth Filler Material (Below 501 904 El 7 r 0 TYPE OF SEPTIC WORK: NE STALLATION l-1 REPAIR/ADDITION I I DESTRUCT I I. lNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other 8 Number of living units: Number f bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ T Method of Disposal Distance to nearest: ell Foundation Property.Line LEACHING LINE ❑ No. & Leng f lines Total length/size FILTER BED ❑ Distanc o nearest: Well Founda Property Line SEEPAGE PITS I'I epth Size umber SUMPS 1 Distance to nearest: Well Foundation Property Line DISPOSAL POND ❑ 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." The applicant m s tali for all required inspections. Complete drawing on reverse side. Er 1167 Signed X � �HC• IIn� Title: f�i r)X4" `"3 af0 116167 e6 Date: — I" r �r FOR DEPARTMENT USE ONLY Application Accepted by �•S . Date �ZZ Area r, 1. rr g—T- Pit or Grout Inspection by (� Date ! Final Inspection by Date Additional Comments: –Sii. a, �':1c wllt lo+x,�..,.s �L, 1-,, dot",o IP RM,Q44 I� 11Stk 466-6781 ❑ Lodi 369-3621 d Manteca 823-7104 ❑ Tra 835,-t385 Applicant - Return)all copies to: Environmental Health Permit/Services 1601 E..Hazelton Ave, P.O. Box 2009, Stk., CA 955201 j (�..,,.• ,,,;61 ..�'a ✓.ie of rSr'co r� FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED!BY DATE PERMIT'NO. CA H a +.EH 1324 tREV.t i it 5) 1 EH 14-26 S a QO CX,-S M