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.�: APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I r 1601 E. HAZEL-10N AVE., STOCKTON, CA Telephone {209}•466-6781 1� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y t: 47'(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 Locai Health District. c Job,4ddress�.�� ` Ff'�T � � � $ city Lot Size PM Owner's Name LZAR-lbI -Address` Phone Contractor/002—V- � Address License No. Phone 117Z 2 TYPE OF WELL/PUMP: ""NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' ► PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE EFOUNDATION ' > AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL7' PROBLEM AREA CONSTRUCTION SPECIFICATIONS /Repair Industrial ❑ Open Bottom. ❑ Manteca' Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel/PIN ❑ Tracy '°_ Type of Casing Specifications .` Public ❑ Other! ❑ Delta Depth of Grout Seal Type_of Grout Irrigation —Approx,-Depth ❑ Eastern ' ,Surface Seal Installed by. 11 Work Done ❑ Type of Pump H.P. xa State Work Done i J Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth 4 t-'Filler Material (Below 501 TYPE OF SEPTIC WORK' NEW INSTALLATION ❑ REPAIR/ADDI710N ]—'DESTRUCTION ❑ (No septic system permitted if public sewer is i, available within 200 feet.) Installation will serve: Residence 'Commercial,_!�rOther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity's' No. Compartments PKG. TREATMENT PLT. ❑ l wedje&rA-_-54-,.?7A9VMethod of Disposal Dis ante to nearest: "Well' Foundation Property Line r � LEACHING UNE l❑ No. &Length of lines Total length/size j Z • y FILTER BED ❑ Distance to nearest:' Well FounOation Property Line SEEPAGE PITS ❑ Depths Size A Number SUMPS ❑ Distance to nearest: Well Foundatgn Property Line DISPOSAL PONDS ❑ I hereby certify that I have prapared this application and that the work will be done is accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. a 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 i employ any person in such manner as to become subject to workman's compensation lam of California."Contractor's hiring or subcontracting signature certifies the following:"I certify'that in trperformance'of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion tion laws of California." ,,� t. _f Al y _ The applicant must cfail for all rreeq�uire�d inspecti ns Complete drawing on reverse side. Signeu" _�' %i�'�""P aTitle'_LY f- �- - Date: ' :FORXDT MENT USE ONLY s Application Accepted:b Date Area - � � DaInspection to Final Ins coon b Date Pit or Grout Inspection. Pe Y Additional ants: ❑ St 6781 6781 ❑ Lad! 369-3621 ❑ Mari c 923-7104 "„^ ❑ Tracy 8354M Applicant Return all copies to: Environmental Health P�mjt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 ` FEE ITTED (NFD AMOUNT DUE AMOUNT REi CASH RECEIVED BY DATE PERMIT'ND. 1105 +-EH 137A(REV.t/a5Y {. EH 1428