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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. (� Inh AHC!,- �f[ 'l�I ! '� 4.h a—(> rity SAM I nt Si7A �J PM I hereby certify that I have prepared this application and that the work wil 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: "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 requ' d inspections. Complete drawing on reverse side. Js s Signed J Title: - —� Date: Z FOR DEPARTMENT USE ONLY j Application Accepted by Tk6r A Date Area Pit or Grout inspection-bY_ —Date -L, ' Final' Inspection by- DateA e FV V Additional Comments: N ' w 1K - /JkStk 46f M1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LI'Tracy + &&63851• App icant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s EH 1324 IREV. 10193) EH 14-26 FEE INFO AMOUNT DUE Owner's Name 0*C4Z-,L Address �C i1Z � � Phone RECEIVED BY DATE r c.<Y- — V 3 96 0 Contractor's Namel,rj License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ c-L-a-r-e� 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 ' ❑ Open Bottom ❑ Manteca .-Dia: of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy - '' 4, ,y Type of Casing Specifications ❑ Public �;� ❑ Other' ElDelta Depth of Grout Seal Type of Grout El 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"501 , Depth Filler Material (Below'50 TYPE OF WORK:: -.NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is �SE�PTIC V ` available within 200 feet.) Installation will serve: Residences `Commercial _ Other Number of living units: 1 Number of_,beArooms r�Y " _ _- _ Character of soil to a depth of 3 feet: F - Water table depth d i SEPTIC TANK ❑ Type/Mfg. 10 Capacity No. Compartments PKG, TREATMENT PLT, Oj` ' y Method of Disposal w Distance to nearest: ' We11 'e Foundation Property Line a LEACHING LINENo&Length of lines 'd _ __ Total length/size iC y�I FILTER BED ❑ Distance to nearest: Well D �` Foundation 1 D + Property Line s SEEPAGE PITS Td Depth Number SUMPS ❑ Distance to -nearest: Well 16-P Foundation f Property Line DISPOSAL PONDS , ❑ I hereby certify that I have prepared this application and that the work wil 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: "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 requ' d inspections. Complete drawing on reverse side. Js s Signed J Title: - —� Date: Z FOR DEPARTMENT USE ONLY j Application Accepted by Tk6r A Date Area Pit or Grout inspection-bY_ —Date -L, ' Final' Inspection by- DateA e FV V Additional Comments: N ' w 1K - /JkStk 46f M1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LI'Tracy + &&63851• App icant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s EH 1324 IREV. 10193) EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO, �s00 ck c-L-a-r-e� 5C5U_1�"� o