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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES T 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. ?I Job Address `T`7`7� NO I�TiR( ''(SER Skil V 67 At/ U F_ City, STOCK�Or� Lot Size PM it �t�a •2r^�J �� Address 1200 .SF11TN ST12GF- HQ%STaN TA Phone 7f3 6567?Sy Owner's Name 11 -� , ' L 3V.- � $t�6g5-6b13 Contractor V �-�/jU�+" f2tfitN(rCaAddress167(o tsDoN 030 . Cof4 a09�icenseNo.�$Z Phone TYPE OF WELL/PUMP: -0EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 50 - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL.E Fr PITS/SUMPS 7� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom ❑ Manteca Dia. of Well Excavation �10 ID' 2 Dia. of Welt Casing ElEl ❑ Domestic/Private ($(Grave! Pack Cl VG --� ,M Specifications sTracy Type of Casing CA-- ^ i 20 fe-c r M Public l=l Other � ?Sd�Delta Depth of Grout Seal � Type of Grout _ I I I ,,cagti --Approx. Depth 1 1 Eastern. Surface Seal ins talled by �Qt t-l✓�n - U 6 &ge-no'i State Work Done Repair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Well Diameter Sealing Material atop 50'} Depth Yi Filler Material (Below 56 TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I 1 DESTRUCTION 1 1 (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 1 Water table depth Character of soil to a depth of 3 feet: r SEPTIG TANK El 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ s Method of Disposal Distance to nearest: Well Foundation Property Line Total len th/size LEACHING LINE ❑ No. & Length of lines 9 I FILTER BED ❑ Distance to nearest: Well Foundation Property Line 44 - r SEEPAGE PITS 11 Depth Size Number SUMPS D Distaste to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ kI hereby certify that I have prepaied ithis 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. s 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 shalt not 4 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, l shall employ persons subject to workman's compensa- tion laws of California." The applicant call for at required inspections. Complete rawing on reverse rside. 4 �1i�1} t tf>✓er, I #'�Io t� Date: 8 �� 19 Signed k Title: 1 FOR DEPARTMENT USE ONLY Application Accepted by Date ' Area _.. Pit or rou Inspection by Date -��'/O�Final Inspection by Date p I Additional Com . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 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 SH RECEIVED BY DATE PERMIT'NO. t INFO + EH 13-24(REV.ti/115) o4 46a /slelo ho -to EH t4-26 i