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APPLICATION FOR PERMIT ,.PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZE T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 SEP 13 egg PERMIT EXPIRES 1YEAR'FROM DATE ISSUED I - , r. •. Triplicate) ENVIRONMENTALHEALTH a r ,,,, a {Complete in Tri licate h , _ PERMIT/SERVICES I 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 Ryles and Regulations of the San Joaquin Local Health District. fW 't sss Job Address [Pry t r citybuazw- Lot Size ri PM f Owner's Name Address Phone Z ' Contractor ' Address C&-96 License No.q - 2C] Phone 2 � TYPE OF WELL/PUMP: ' NEW WELL ❑ WELL REPLACEMENT ,❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 91111 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 Domestic/Private ❑ Gravel Pack El Tracy" Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! Type of Grout ❑ Irrigation --Approx. epth ❑ Eastern Surface Seal Installed by Repair Work Done It Type of Pump �. H.P. �l _ 5tate Wark one ' Well Destruction ❑ Well Diameter °- �,� Sealing Material (top 50')h1Er v 1 Depth Filler Material (Below 50'){_/- � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is r available within 200 feet.) ` Installation will serve: Residence Commercial— Other Number of living units: _Nu_mber of bedrooms Character of soil io a depth of 3 feet: .1 - Q ff Wafer iable'-depth SEPTIC TANK ❑ Type/Mfg `1 ;� k, �. .__ �''#TREATMENT Capacity No. Compartments . REATMENT PLT:❑ w `�`'`° "" R =�` Method of Disposal v Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ N Size Depth I h umber SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ e _ 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 Joagtin°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 ust coil for all required inspections. Complete drawing on reverse side. I Signed f Title: ,2 Date: FOR DEPARTMENT USE ONLY Application Accepted by i . Date ^ CJ Area 165 Pit or Grout Inspection by J Date Final Inspection by Date-- Additional Comments: k ❑ 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 of INFO CASH RECEIVED BY DATE PERMIT"NO.. + EH 13-241REV.i/s sl 5 f/.� aQ�� EH M26 ��/`i