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NORA..- � Y APPLICATION FOR PERMIT SAN JOAQUIN .LOCAL HEALTH DISTRICT 1601 E. HAZEL -TON 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. t. �. Job Address /y O-/� . �l. L� • _ 3 . ycity — Lot- Size PM Owner's " NameSTipi%lf/✓%�f� �.. _ -Address 1545 Ad., VE =— Phone Contractor's Name l CdA"Z License No. 2- gS Phone Trc Ur vvtLL/rumr: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ industrial t . ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Public t r k ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation --Approx: Depth ❑ Eastern Surface Seal Installed by Repair Work, Done ❑ Type of Pump H. P. State Work Done _ Dia, of Well Casing Specifications Type of Grout — Well Destruction ❑ y Well Diameter Sealing Material (top 501) �. Depth I Filler Material (Below 501' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if i f ' �- available within 200 feet.) Installation -will serve: Residence X_ 1Commercial — Other , s/.Ss - 453 sewer is Number of living units: Number of bedrooms �— Character of soil to'A depth of 3 feet: Water table depth .SEPTIC TANK "1,�9_ Type/Mfg PO4 L10/1/lPE7,5 Capacity_Z No. Compartments O PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:. Well Fr Foundation 12-'A Property Line 3 4 FT LEACHING LINE FILTER BED 1 ❑ No. &Length of lines .3 Total length/size 2-1 FT ❑"Distance to nearest:. 'Well �srf Foundation .30 Property Line Z2_ FT' SEEPAGE PITS E ElDepth Size Number I :SUMPS f ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS, a❑ .► 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." Contractors hiring or sub -contracting signature certifies the followin : "I certify that in the performance of the work for which this permit is issued, I shall employ pennons subject to workman's compensa- tion laws of Calif The applicant t ed inspections. Complete drawing on reverse side. AsignedTitle: r/6GI>�r/d= 4OV7 4 4 Date: /Z - r_ -FOR DEPARTMENT•.USE ONLY - - Application Accepted, by Date l a�� , Area O� Pit or Grout Inspection by I_ a Date Final Inspection by _ l �� DateQ��L Additional Comments: s G O Q 0 r ,. � I yI h pr _6 0 -Stk 466-6781 . 'El Lodi 364-3Q11 . - ❑ Manteca 823-71 - 1-1Tracy 835-6385 --- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box2009, Stk., CA 95201 + EH 1324IREV. 10!83 EH 14-28 ' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT" N0.