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APPLICATION FOR PERMIT PAYMENT c RECEIVE© SAN JOAQUIN LOCAL HEALTH DISTRICT j►` - 1601 E. HAZE T ON AVE., STOCKTON, CA >� At Telephone (209) 466-6781 NEAR 28 11990 I V D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ##A ENVIRONMENTAL HEALTH (Complete in Triplicate) � ` � PERMIT ppV�F fCom ftlR Application is hereby mad!§9'�he B9Joaquin Local Health District for a permit to construct and/or install the work T plication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a tTi 11 E��`i'.Joaquin Local Health District. 1 Job Address xtoo we-�� City Lot Size ;3 3 > c PM Owner's Name INZW 3' -4��s�. C %. Address OS — 9'Ahon_e . R. C.0, Rags!—n5"70 Contractor Z�sNAddress Z S License Ho,SQ13K'+l Cs?Phone TYPE OF WELL/PUMP: NEW VkLL 9 tyel L*k9- WELL REPLACEM NT ❑ UCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK N SEWER LINES 71h6r._->_ DISPOSAL FLIT. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS It ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation to Dia. of Well Casing ❑ Domestic/FO`ivate I�a Gravel Pack ❑ Tracy Type of Casing C Specifications r f f`l Public ❑ Other Q4,Delta Depth of Grout Seal L `1 Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump Fel/4 H.P. QAr State Work Done Well Destruction ❑ Well Diameter �J If Sealing Material (top 501 MC)r\V��e A Depth J ` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted it 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 r 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 Al Number i SUMPS ❑ Distance to nearest: WellFoundation�_ Property Line DISPOSAL PONDS Ll • � 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. 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, f shall not i 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." - i 4rhe applicant must call for all required inspections. Complete drawing on reverse side. ' Signed X Title: Strom_,Cm-%- �r n�cxt 1X+ Date: F PA T USE ONLY / Application Accepted by Date f Ar Pit or Grout Inspection by Date ` Final Inspection by Date lell 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 INFO AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT NO. ♦ EH 13-14IREV.tinsi ,S �� 12 cl