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rr ,• � ' �� . �" r r k1. a',�p. ,J - _'. APPLICATION FOR PERMIT I SAN JOAOUIN LOCAL HEALTH DISTRICT �r 1601 E. HAZELTON AVE., STOCKTON, CA D I] ll��j�t � i Telephone (209) 466-6781 �G �+ PERMIT EXPIRES 1 YEAR FROM DATE ISSUE ., ------ --- ------ _-- OCT 1 I W9 (Complete in Triplicate) Application is he eby made to the San Joaquin Local Health Distract ror a permit to construct and/or Install f )A+(Pl� M FII application is made in compliance with San Joaquin Counry Or�,linance No.!r49 for sewage or No. IB62 for well/pump and the Rpt RMIT?%, " � h San Joeavin Local Health District. y f Job Address ___27_539_S_.—LAKE_RS_RDCity _TRAC_)�-- Lot Size PM _ Owner's Name PAUL PISHOS Address 31 ST EA ( TH_ST. _TBACY,�A— Phone A37-A()AO- __—_ — - Contractor-j-ISN- NG"RIIS__DRTL_L_Address3_52_5-_P-E4-AN9AL-E AVI_License No.2_g0B 3—Phor-�54�i-��A5 TYPE OF 1"!ELVFUP:IP: NEW WELL IX WELL REPLACEMENT CJ DESTRUCTION ❑ = PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SErTIC TANK —U-G--+- SEWER LINFS AGO 1+ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL _— OTHER WELL PITS/SUMPS INTENDED USE TYPE Or'J:LLL ,^nUBLEM AREA CONSTRUCTION SPECIFICATIONS -- f_, Manteca Dia. of YJclI Excavation 12° 0' of Well Casing 6 ❑ Industrial CJ Open Bottom �6� �1 Oomeetic/Private Gravel Pack If r(Tracy Typo of Casing P t Y _ cifications 1-1 Fibl,c n Other Il Delta De,.th of Grout Seal ype of Grout RFN.L(IN TE I I litigation —Approx. Depth I E2storn Surface Seal Installed by H E N N T N C S R RO S n Q_ 1 1�T.4fj�0 Repair Work Done L7 Type of Pump H.P._-__ State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50 r Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I R1.1.SIR/ADDITION I I DESTRUCTION I I (No septic system permiaed if public sewer is } available within 200 feel v5 of 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/Mfr Capacity _.— No.Compartments S PKG. TREATMENT'PLT ❑ Method o!Disposal r Distance to n^_west: Welt Foundation. Property Line r _ Total le th/size- S LEACHING LINE C1 No.P,'•englfi of lines n9 FILTER BED ❑ Distance fo nearest: Well_—__ Fnundation ''roperty Line r ! SEEPAGE PITS I I Depth Size Number - StIMPS Ll Distance:o n crest: Weil F;nindation Property Line DISPOSAL PONDS M I hereby certify that I have prepared this application and that the work will be Jone in accordance with Gan Joaquin county ordinances,state laws,and A rules and regulations of the San Joaquin Local Health Di3trict. _... ,,. Noe owner or licensed agent's signature certifies the following: "I certify that in ttw performance of the work for which this permit Is Issued,I shall not permit employ any parson in such manner as to become subject to workmar's compensation laws of California.-Contractor's hiring Of sub- I'setirq signature certifies the fotbwing:"I certify that in the performance of If r work for which this permit is issued,I shall employ pens^:.:subject to workman's cor'Ipensa31 11 - tion laws of Canfornia." -} ¢• The applicant must call for all required inspections. Comple�t,,e��of w, n reverse side. i p. Signed X_ eQ„ i � s��s Ti1l r Date: FOR DEPARTMENT USE ONLY � y Application t.ccepted by __�lJ � Date Final Inspection by e Pit or Grout Inspection by . r Additional Common's: y ❑SO 461557/dt ❑ Lodi x621 0 Manteca 823-71`4 ❑Tracy 835.6385 Applicant-Retirn a!I copies:o: Environmental Health Permit/Services E. Hazelton Ave., P.O. Box 1009, Stk.,CA 9'201 o Y, Ariza 17 —_ l/ f },15 CK 11 FEE AMOUNT DUE AMOUNT REMITTED AT CASH RECEIVED BY DE PERMIT•NO. INFO . 113-24(REV.,i�t.l( FH,.-z3- 9-A 833 � � I, � �,�ry�„�.�.�...� rax.-• -,n c,mNa�s s rict;y _ Eti� :� �,,.,�... urt s