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APPLICATION GOR PERMIT .N JOAQUIN LOCAL HEALTH DISTR 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Y 74 7 Application is he)eby made to the San Joaquin Local Health District for a permit to construct itidAorInM±�the,Pyork�hei i described. This application is made in compliance with San Joaquin CountyOrdinanceNo.549 for sewage or No. 1862 for wef tj. imp and the A'uIcii3n�d Regulations of the San Joaquin Local Health District. 7 ' Job Address �c.�Y I�C-i1 •'Q-:�16oG l!cm t)�S�Irc_t(,T- City t• _ / Lot Size PM cart: kX�, -310 5.40� ICA Ow�nelr'sNamef(1�'`>7 :51ht=__� 'F��"TiC,V Address 10 I1cPhone1� t" j WL' 1- ��i<vc,P_ uP tc;Utl(14,J��/lt�;+.ry?tr �YS:I=A. PERM' Contractor OES7 AIA2- 1l Address 327 3 (-'l'° Irl<�� License Phone?// n ""'Z7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN C7 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER;Q,r DISTANCE TO NEAREST: SEPTIC TANK SV r SEWER LINESy( DISPOSAL FLD. >O PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation (c7 ' Dia. of Well Casing A.)L ? ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing tk)r'�?UL7 Specifications f'1 Public Cl Other f 1 Delta Depth of Grout Seal a Type of GroutCG�urirr.t�f 1 1 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 Itop 50') Depth Filler Material (Below 501 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 r Distance to nearest: Well Foundation Property Line v 1K LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lin S SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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 applic7us. t call for all required inspections. Complete drawing on reverse side. C Signed X ^--, Title: ��(--0�>f ST Date: C,M_tr-L-11 ORD TMIENTUSE ONLY Application Accepted by Date / Area / Pit or Grout Inspection by Date 1� Final Inspection by Date or Additional Comments: ❑ Stk 466-6781 O Lodi 369-3627 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .41 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 O FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED EY DATE PERMIT'INO. INFO I CASH . EH 13.24(REV.t i x S) 71 6 EH 14.26