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APPLICATION FOR PERMIT 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. 549 for sewage or No. 1862 for wait/ pump and the Rules and Regulations of the San Joaquin Local Health District. 7 E. Co ero olis Job Address 2126 PP P _ _ � cltv Stockton ' , I ,,, c;,e 2.3 Acres ora r r, -Vy canny Enai r nava prepnreu Erns appocauun ana rnax Tne WOM will De crone In accordance With San Joaquin county ordinances, state laws, and rules and regutations 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 parformance of the work for which this is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must all uired inspections. Complete drawing on r erre ' e. ign Title: Dater FOR DEPARTMENT USE ONLY Application Accepted by - Pit or Grout Inspection by Date !-3p ] Area Final Inspection by _ _� L�–s,,�a�,. Hate Additional Comments: } LStk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 ' Ap6licant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 1321 (REV. 10183 EH 1426. 1FEE0 AMOUNT DUE AMOUNT REMITTED CK ., Owner's Name Zany Peters Address 119 W. La Mesa Phone 26� 952-9434 Contractor's Name. Jerry Joy AssOCiatekicense No. 394241 phone 5209 462-1481 TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.-- PROP, EINE FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS INTENDED USE TYPE OF WELL PR06LEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material [Below 50'1 TYPE OF SEPTIC WORK. NEW INSTALLATION XX REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence �x Commercial — Other Number of living units: 1 Number of bedrooms Character of soil to a depth of 3 feet: _.sandy Clay &_ loam Water table depth SEPTIC TANK 19C Type/Mfg concrete Capacity 1200 No. Compartments two PKG. TREATMENT PLT. ❑ Method of Disposal leach & Rits Distance to nearest:. Well Foundation Property Line LEACHING, LINE :PC No. S Length of lines tw.d _ (2) _ Total length/size 15-0-' r FILTER BED ❑ Distance to nearest: Well 200+ Foundation 75+ Property Line 150+ SEEPAGE PITS �Pc Depth 25' Size 33'r Number two SUMPS ❑ Distance to nearest: Wetl 200+ Foundation 75+ Property Line 150 r DISPOSAL PONDS ❑ f r r, -Vy canny Enai r nava prepnreu Erns appocauun ana rnax Tne WOM will De crone In accordance With San Joaquin county ordinances, state laws, and rules and regutations 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 parformance of the work for which this is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must all uired inspections. Complete drawing on r erre ' e. ign Title: Dater FOR DEPARTMENT USE ONLY Application Accepted by - Pit or Grout Inspection by Date !-3p ] Area Final Inspection by _ _� L�–s,,�a�,. Hate Additional Comments: } LStk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 ' Ap6licant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 1321 (REV. 10183 EH 1426. 1FEE0 AMOUNT DUE AMOUNT REMITTED CK ., RECEIVED BY DATE PERMIT"IVO. -fir a X943 is/3 $Ll 13€7 f