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vt APPLICATION FOR PERMIT PAYMENT w SAN JOAQUIN LOCAL HEALTH DISTRICT RtCEIVED A" 1641 E. HAZEL T ON AVE., STOCKTON, CA 4 Telephone (209) 466-6781 im 2 6 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT1SERVICES-rt"�-- 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. Job Address _,2 I � /X City r Lot Size PM Owner's Name Address Contractor Address �J�r� .� icense No. GZ_ --Phone �r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -/� -SEWER=LINES -��-T- "DISPOSAL'-FL-D.�,�-PROP:-LINE�O--- ° �-�-tom ...DISTANCE'TO-NEAREST:-SEPTIC-T-ANK-�-_.E.—""'" .FOUNDATION AGRICULTURE WELL OTHER WELLI PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )I Domestic/Private N Gravel Pack X Tracy Type of Casing te Vg• Specifications M Public 1-1 0 er ❑ Delta Depth of Grout Seal f Type of Grout u&- 1.1 Irrigation -V .Approx. Depth l l Eastern Surface Seal Installed by - I Work Done ❑ T e of Pump H.P. State Work Done Repair Wo yp Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial____ Other i 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 Distance to nearest: Well Foundation Property Line " LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line h lI e SEEPAGE PITS 11 Depth Size _ Number Ll LA Distance to nearest: Welk *Fo dation�� Pfoperty 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 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 mu t call for all requir inspections. Cam late drawing on a arse si e. p Signed X Title: t" Date: 7,z F + PA MENT USE ONLY _ Application Accepted by �i Date 7 C f Area Pit or Grout nspection by g Dater Final Inspection by Date Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO �f k r.EH13-24tpEV.rih451 fid ft, �� " 3-7gq [ EH 14-26 ` 3