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IUI M1, HU UHIVt.Jul. aOU SAN JOSE,CALIFORNIA 95110 • PLICATION FOR PERMIT • C09-2e6-0100 ES QUIN LOCAL HEALTH DISTRICT AZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 Timothy B. Tyler PIRES 1 YEAR FROM DATE ISSUED Staff HydropeoloClst (Complete in Triplicate) JAL I �rn District for a permit to construct and/or install the work herein described. This application is Ttwie'2 1W ` f a-o (� .549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Job Address � oz pp011 tl Ll 1�- City Ste_ Lot Size PM Owner's Name �C C?-C) I _ Address _ Phone \�\ ��t �( W.P177S Bf,�t r Contractor IIwm (?L012ftJ 6111 Address 44V E7VZ'2A ST License No. 76-08 ' Phone4f5- 662--5'50 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER la' 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 D Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private D Gravel Pack D Tracy Type of Casing Specifications PI Public D Other I-I Delta Depth of Grout Seal Type of Grout_ I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Vlfork Done D Type of Pump H.P. State Work Done _ Well Destruction_ [),__Well Dianlgter, Sealing-Material (top 50'1 f Depth Filler Material (Below 50'1 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RI PAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is G available within 200 feet.) Installation will serve: Residence_ Commercial_ Other l� Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. LI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 8 Length of lines Total length/size (� FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ — _. Number SUMPS I I Distance to nearest: Well Foundation _ _ Property Line `/YY DISPOSAL PONDS I 1 I hereby certify that 1 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 spections. Complete drawing on reverse side. p Signed X `J . 7 ____._ __ Title: IV YO Poo,EOL UC, r 5 i- C--s C Date: 3111186 - FOR DEPARTMENT USE ONLY �}7 ,O Application Accepted by L/7'J// e _ Date l" L' Area Pit or Grout Inspection by ' �l,5hy�-- D.. - S� Final Inspection by Additional Comments: _ 0 Stk 466.6781 0 Lodi 369-3621 D Manteca 823-7104 0 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 REMITTEDRECEIVED BY DATE PERMIT'NO. INFO Ell (��`.�� p .G • EM;4.EN f,.�IREV.Ire51 3S. ��LV 9 .J Z