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r i. Z. , .. {;o• V � ry H+.,F..- �.)�nr� �' y'� a^...yT-+ Syrmu, 1601 E. HAZELTON AVE., STOCKTON, CA F1 Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ot 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 Job Address ._._. CSP€Av �k->_- City s7i�_Ap Lot Size PM [ Owner's Name /6l4: of b Address ..__tea 2!r6i1 _ Phone I �i Contractor's Name F!-... jEz> di . 4.J0C1-Z> License No. t-- ___ Phone 7 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS —_ if INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C1 Open Bottom ❑ Manteca Dia_ of Well Excavation _ Dia. of Well Casing ❑ domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other El Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump, H.P, State Work DoneF i r U Well Destruction ❑ Well Diameter Sealing Material atop 501 V Depth Filler Material (Belo 50') s TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION p iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: __/_ Number of bedrooms ?_� C Character of soil to a depth of 3 feet: Water table depth ] SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments E PKG. TREATMENT PLT. ❑ K i s Method of Disposal Distance to nearest: Well Foundation Property Line _ 1 LEACHING LINE No. & Length of lines f — / _ Total lengthlsize [� ' FILTER BED L1Distance to nearest: Well,' � Foundation 3c2 ' Property Line ZS R SEEPAGE PITS Depth Size -13 �� _ Number SUMPS ❑ Distance to nearest: Well .10�2' Foundation O Property Line DISPOSAL PONDS Cl 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 must call for all required inspections. Complete drawing on reverse side. Signed X�` ,� Title: —. Date: 2:�9—Er FOR DEPARTMENT USE ONLY Application Accepted by � t �p,, -�--�� Date" V Area Pit or Grout Inspection byalp Final Inspection by a__��..- �a.M�Ca_._ate 3� E r Additional Comments; _ ❑ Stk 466-6781 ❑ Lodi 369=3621 ❑ Manteca 1323-7104 ❑ Tracy 835.638.5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 t C FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. E' EH 13-24(REV.101931 EH 1426