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0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA t 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, �`% .Inh Address 9 / k/3 C t Oc /k) lJ (:itv _) I nt Sipa +)1J ' / % if PRA 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:' nify th the pe a of the ork for which this permit is issued, I shall employ persons subject to workman's ompensa- tion laws of C ' orni �.�__� The appli mlLfa e ed " sons. C of drawing on revere si Signed X \1 l5�' Application Accepted bVk Pit or Grout Inspection by Title: oVV AJ Date: FOR DEPARTMENT USE ONLY Date 7--10 —A? V Area Date Final Inspection b 1 l0 NOT _ 4C AQ— )56C Date ` 6 Z) vsn6Z M h Additional Comments: U / ❑ Stk 466-6781 ❑ Lodi 369-3621 -- ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4, + EH 1324 (REV. 10183 EH '14-26 i FEE INFO AMOUNT DUE AMOUNT REMITTED "Llp% O Z/dd Owner's Name V ddresbClvll Phone PERMIT•`NO. 4114 C_ Contractor's Name C A,(" G Oz, se No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ — PUMP INSTALLATION r — SYSTEM REPAIR LJ �r OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK _hoo SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA719iqT7dr�f ❑ In�vial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [-Dm oestic/Private ravel Pack ❑ Tracy Type of Casing Specifications 4�1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal " / Type of Grout ❑ Irrigation . --Approx. Dept stern S� ace Seal Instslled bye r Repair Work Done ElType of Pump^/�� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (t p 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 Distance to nearest: Well %Foundation Property Line LEACHING LINE ❑ NoA Length of lines Total length/size FILTER BED ❑ Distance to nearest Well f Foundation Property'Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4F .� 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:' nify th the pe a of the ork for which this permit is issued, I shall employ persons subject to workman's ompensa- tion laws of C ' orni �.�__� The appli mlLfa e ed " sons. C of drawing on revere si Signed X \1 l5�' Application Accepted bVk Pit or Grout Inspection by Title: oVV AJ Date: FOR DEPARTMENT USE ONLY Date 7--10 —A? V Area Date Final Inspection b 1 l0 NOT _ 4C AQ— )56C Date ` 6 Z) vsn6Z M h Additional Comments: U / ❑ Stk 466-6781 ❑ Lodi 369-3621 -- ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4, + EH 1324 (REV. 10183 EH '14-26 i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•`NO. �siss c� o q /1 �/ , T�1-I 11�q IJ ld