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}' APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZE T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 MAY RECEIVED PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH E� SAY 191988 (Complete in Triplicate) PERMITJSERVICES 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 Q 1rFjKryp�q�q i ounty Ordinance a No 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local HeaVlf r , -; ., . (SERVICES Job Address. 1!i�J93� w' � City Lot Size PM Owner's Name ddress [/ /Phone "�1bs Contractor LEL Address *,3Jas GLttGCUCL 1/496.License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT )K DESTRUCTION ❑ PUMP INSTALLATION L] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /00 a SEWER LINES DISPOSAL FLD. IM' PROP. LINE .,q FOUNDATION AGRICULTURE WELL OTHER WECL=:3T• PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation //__ Dia. of Well Casing Domestic/Private V Gravel Pack 171Tracy Type of Casing pW, - - _ / Specifications (�} ❑ Public n Other ❑ Delta Depth of Grout Seal Type of Gaut L I I Irrigation - —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done Q Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth Filler Material (Below 501 L}/ TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION l 1 DESTRUCTION I I iNo 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 G d Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size 137 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L] 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, ander 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 n employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 law's of California." The applicWZZO) all required inspections. Complete drawing on reverse s�Ia Signed � Title: L Date: FOR DEPAR ' ENT USE ONLY I� l � dk Application Accepted by Date ? '� `� Area I Pit or Grout Inspection by �YlData - Final Inspection by Date I 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 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24(REV.1 5) —7 EH 14-211