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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 JAN PERMIT EXP)RES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1WRONMENTAa_ HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dk ./%R"f�Qtion 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 Toaquin Local Health District. �,, Job Address /45 25AJ City ��X/��— Lot Size PM Owner's Name tA4rvt Address di?D, lbie /10 40d1'. lA 1� _ Phone RS6z`l I Contractor_C 1�d920L4in.4 _ Address PO Y S �• E[e 69C94<6A., License No.�13`f3�/�Phone / TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR � OTHER X ReCOVAe7WeAL DISTANCE TO NEAREST: SEPTIC TANK A1�4 SEWER LINES � DISPOSAL FLD. &Z--4 _ PROP. LINE FOUNDATION S`AGRICULTURE WELL �� OTHER WELL �A PITSISUMPS A4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private V Gravel Pack ❑ Tracy Type of Casing JOjlC Specifications (}� ['1 Public /�ft'aVfif &L,1541- t , Other F1 Delta Depth of Grout Seal s Type of Grout odfdl-0616 f_ SlQ I 1 Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by A?IE_ 0016E__ Repair Work Done (3 Type of Pump — r/A H.P. State Work Done— Well Destruction El Well Diameter Sealing Material Stop 501 M Depth Filler Material (Below 50') 4 TYPE OF SEPTIC WORK. NEW INSTALLATION l I REPAIR/ADDITION i I DESTRUCTION ( 1 (No septic system permitted if public sewer is 1 available within 200 feet.) Installa will serve: Residence_ Commercial— Other Number of linin its: Number of bedrooms Character of soil to a de �of 3 feet: ate, table depth SEPTIC TANK ❑ Ty _7 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Foundation Property Line LEACHING LINE o. & Length of lines Total length/size FILTER BE ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS F1 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 t call for all u ed inspections. Complete drawing on reverse side. Signed X J Title: PR:�JA:�T G4bZQ6,5T Hate: // Z �X_ _ t FOR DEPARTMENT USE ONLY r Application Accepted by Date f r r� Area l Pit or Grout Inspection by - Data Final Inspection by Date 1 Additional Comments: ❑ Stk 466-6741 ❑ Lodi 369-3621 ❑ Manteca 823.7104 13 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. CASH INFO • EH l3-'.41AEV.1; •5, 73 S EN.26C--- /1,v�� .