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APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DIST _ 1601 E. HAZELTON AVE. STOCKTON, CA Telephone (209) 466-67$1 i_ a: PERMIT EXPIRES 3'YEAR FROM DATE ISSUED fl, AR (Complete in Triplicate) N 7 P.,, ice^` ) ! , 1 V � � t �. L i �i 1 Y� 1 r' : CI I :� � Z� r � r T �"S Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ��ig-des�rib Tfn's pplfdarion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/ pump and the Flule tri r Regtdat9 +69 ilia San Joaquin Local Health District. Ar,,_ 6.20 .San`Tt1ln.n AtJe,. r;.,,.45-7 L+r5n r,,. Sino 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 shalt 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/ inspections. Complete drawing on reverse side. Signed XJ -.Title: W Date: FOR DEPARTMENT USE ONLY Application Accepted by Date S (� A�rea� Pit or Grout Inspection by Date Final Inspection by `= Date Additional Comments: ry vv t t t^-- \ ry11 J Cl Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385�� W1�JL,[� 1�ii�fS' Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P. A 9 NOISIAIQ H.I.�NQXT UM FEE bV0fAVS + EH 13.24 (REV. 7 i R 5 EH 14-26 INFO e 1D Lee- WTI!) ro s Owner's Name Hrs. Zon a (!!6caft Ax, Address Q O. f` nx (Sk 1 S� C kb Y'} Phone 3 + f Cx eel lcr. Contractor akr 16S, Address_13 i"La111 to �icenae No. S96 Phone S- 000, TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERA SOI [ P_knrlr, C� q) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'f" 5d �__ _ _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'Domestic/Private ❑•Gravel Pack ❑ Tracy Type of Casing---12� ItPly Specificationsn f'I Pudic Other �•{n►',,I�b�Delta Depth of Grout Seal �Type of Grout.�`�' I I Irrigation _.App ox. e t Eastern Surface Seal Installed b*��. _ Repair Work pone ❑ Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 -1 REPAIR/ADDITION I I DESTRUCTION [ 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 Distance to nearest: Well Foundation Property Line LEACHING LINE r ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 shalt 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/ inspections. Complete drawing on reverse side. Signed XJ -.Title: W Date: FOR DEPARTMENT USE ONLY Application Accepted by Date S (� A�rea� Pit or Grout Inspection by Date Final Inspection by `= Date Additional Comments: ry vv t t t^-- \ ry11 J Cl Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385�� W1�JL,[� 1�ii�fS' Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P. A 9 NOISIAIQ H.I.�NQXT UM FEE bV0fAVS + EH 13.24 (REV. 7 i R 5 EH 14-26 INFO AMOUNT DUE AMOUNT REMITTED CASH 1-