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PAYMENT APPLICATION FOR PERMIT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA AUG i o m Telephone (209) 466-6781NyrRpNME PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ALRMIT/SERy1 HE (Complete in Triplicate) r 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 w Local Health District. l Job Address �'• f City Lot Size PM f Owner's Name F 4_aAXAddress Vnz Phone "2L-,2 Contractor, e� 'u Address/[�7��Grn�s�ar ;f' License No.V/�_-_�� __Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Eie [ 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I t.Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t`1 Public 1-1 Other F] Delta Depth of.Grout Seal __ Type of Grout --- I I Irrigation --Approx. Depth i I Eastern ,,Surface Seal Installed by _ Repair Work Done t Type of Pump-,4ad-k' H.P. ____ State.Work Don is Oil, Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 4 • a Depth Filler Material /Below 50'i TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is _« available within 200 feet.} w Installation will serve: Residence=+ti',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 �n PKG. TREATMENT PLT. ❑ Method of Disposal v(�1 Distance to nearest: Well Foundation Property Line v { 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well i Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i I 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 Dt%trict. t 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 cartify 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." s The applicant must scall for all required inspections. Complete drawing on"reverse side. y /10V Signed X • A0.4�v Title: & A. Date: F EPARTMENT USE ONLY Application Accepted by Date Area / r Pit or Grout Inspection by Dat Final Inspection by Dateo Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE { PE�jRMIIT'/N,O. . EH13-24 IREv.1/K 51 �J 3S �J(c "r�p �•�/�V EN 14-28