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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 AUG 1980 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH PERMIT SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he in 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 /85' Cite Lot Size PM Owner's Name 'J l / `� Address/19 �Z ' [.�L L �"��+ Phone "% Contractor 1.d/ Address & License No.16a_5 Phone Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 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 O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth 1 I Eastern Surface Seal Installed by , F � _ Repair Work Done jJ Type of Pumps H.P.E State Work Done Well Destruction ElWell Diameter Sealing Material (top 501 Depth Filler Material (Below 501 V Ti —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 1 (No 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 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 I 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 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 applicantDust call r all required inspections. Complete drawing on reverse side. Ile Signed X � � Title: 7 p/Y Date: DEPARTMENT USE ONLY Application Accepted by Date Area �Q Pit or Grout Insp ction by ate Final Inspection Dated y ,?.�' �.,sr/� l u/C` .e /. Qs G 1��T 7G` ?f !fit` !✓/?"F �iV' � +t'.�"+e,'" �` Additional Co n9ments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835- 5 Applicant- Return all copies stto: Environmental Health Permit/Services/16001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �� //.f%f-� /.m'�C7ha.R�!.w,y. ,�.J�,/2+!.�'ryI" /�I ,.ml .p //'�i.ACIC A� K.f1�"A� �.l"•�.�t/t�''-. c >i.�'.,,`r�`i'�",tea. ,fti �f°w, ygp FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.1/x 5) 3S &' uet EH 14-26 i