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.. APPLICATION FOR PERMIT PA 10WIN LOCAL HEALTH DISTRICT REMI%fLFlW_EL T ON AVE., STOCKTON, CA ## ll ��QQ�Telephone (209) 466-6781 47?�4. P Ef`EMAES 1 YEAR FROM DATE ISSUED SAN JOAQUIN fij 1t�',;, fete in Triplicate) PUBLIC HEALTH cE,.v:.,�� ;4 — 6ce0 Application is hereby made to the WN&NNEW lal"E ti;865t1�11014 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. � f u�/,"5©-^ Job Address SECC2N,. y �r City Lot Size _;'S'2O X PM Pk' 0711 y ` Owner's Name Address Phone 41 1 Contractor EA6L Address^ ><� � ST T�Eft-ONT License No. _�542� Phone Z:5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ (; kaki 63 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X(ZeoYec.li f Rtt l�3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation e.,-a" Dia. of Well Casing __-)A ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 9A --- Specifications �S FI Public (_� Other ❑ Delta Depth of Grout Seal 114�20 Type of Grout CE _ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth''-lox, .._ Filler Material leelow 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION (') REPAIR/ADDITION l 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 L7 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number 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 Di§trict. 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 must call fo II r red inspections. Complete drawing on reverse side. Q Signed X + Title: Date: I y FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection Date Final Inspection by- Date Additional Comments: .A3S Lk fi., d- 4 ❑ Stk 466-6781 ❑ Lodi 36kb621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH 13-241NEV14 ,5/x51 1 EH 26