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APPLICATION FOR PERMIT PAYMENT '+ SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED ! 4 1601 E. HAZELTON AVE., STOCKTON, CA r, I Telephone (209) 466-6781 AUG 2i 1g�� PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) RONMENTAL- HEALTH PERMITJSRVIC5s 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. �j�,.�%f� Job Address y �42,ru l �' City S/�-� I(Lot Size PM Owner's Name7o-wu Fa,Ob Address 'Sa t-*t Phone Contractor lA Address A S 5.2a5- License No.&21 p00 Phone 2f F6 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL'CATiON`[8�� SYSTEM REPAIR C1 OTHER 17 r 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 (N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [7 Public C Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation '2Q0,__Approx. De th I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 1s-5) State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200#eet.i Installation will serve: Residence_ Commercial____ Other ' Number of living units: Number of bedrooms R Character of soil to a depth of 3 feet: Water table depth `� 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line '=^�SEEPAGE-PITS FI-I"-Depth- Size Number SUMPS Ll 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 Di'§trict. 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 applican ust call for requir d inspections. Complete drawing on reverse Signed X Title: Date: J L_ /I DEPARTMENT USE ONLY Application Accepted by Date Area -211 >I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 t.1� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NOINFO . 3� 35 9s 0 + EH 13-24 1REV,I/n s) 1 EH 14-28 Aw