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~ APPLICATION FOR PERMIT 170, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address`a�rcc-Y Ci.se d. f(txr 'LL.♦1 CitVOC-kTO1J Lot Size PM Owner's Name (f " 0NJP-011 0 •�- �. AddressL Z 1�u-INWgEI. N &1-TLE 2-00 Phone Conbacto&E -Q QO, Address 40$0 _�>I V-I I \Z) License NA343�A 3 Phon IS Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER JT W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '40 'V--r DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II 11 ❑ Industrial ❑yy Open Bottom ❑ Manteca Dia. of Well Excavation, O• Dia. of Well Casing ❑ Domestic/Private AnG C1r aysl Pack ❑ Tracy Type of Casing e_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal $ jl�'f Type of Grout ❑ Irrigation ZSIP�Cpprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter LA i^r L-k Sealing Material (top 50'1 rA0,Acor• K tr.e" Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if publicwar is available within 200 feet.) re 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 ❑ 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 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 a ust call for all requir 'nape 'ons. Complete drawing on reverse side. like Date: 1 O— dla O E, R T USE ONLY Application Accepted by Date 0,rea Ph or Grout Inspec ate - nal Inspection by Date,l, r Additional Com nts: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9011 FEE AMOUNT DUE AMOUNT REMITTED INFOCASH RECEIVED BY DATE ►IJIMIT'NO. . EH 1}24(REV.i/xsl EN 1L — - / 2!