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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. south of Job Address Corral hollow goacl City Tr"wLot Size PM Dept. of Fish find GwRe, Region II Owner's Name tote of California Address 1.701 Nipbus Rd.. Rancho Cordovaoh,114 X916)355-7010_ 1780 Vernon St. 95670 Contractor_PC 1�jTloration Address l osey3.11e. CA 9567$ License No.265556 Phone(916)783-9731 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [4 Monitor Well. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF_AAP_ __ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 10 4 " Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LI Domestic/Private C] Gravel Pack ❑ Tracy Type of Casing PVC Specificatio ['I Public ❑ Other ❑ Delta Depth of Grout Seal ' — T & t/benioYLl Type of Grout 11 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 501 Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS 11 Depth Size_ ___ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 I hereby certify that I have prepared this application and that the work will be clone 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 must call for all required inspections. Complete drawing on reverse side. Signed X___�J" f QA�d Title: !- Date: z O G d _�,/ FOR �,]'�,pART 1 USE ONLY �^ Application Accepted by ---<�+ `=—I�--F1 w Date 7' /C'� Area f� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: /��/ �C/ .//©Ii 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante a 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 INFO RECEIVED BY DATE PERMIT'NO. . EH 13-24(REV.i/x 5) EH 10-20 LT