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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 OCT 4 1988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) VIRONMENTAL HEALTH PERMIT f SERVICES 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. Job Address Ci Lot Size PM Owner's Name �, Address Phone Contractor- �e"0V'r�}*■'�,� Address) r License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER JL 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 ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation y ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done It Type of Pump��.� H.P.I/A _ tate Work Done �2 P Well Destruction ❑ Well Diameter Sealing Material (top 50') rr Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo se tic system permitted if public sewer is avallabTe within 200 feet.) Installation will serve: Residence»r_, Commercial— 0{her s Number of living units: Number of bedrooms y Character of soil to a depth of 3 feet• Water table depth SEPTIC TANK ❑ Types/Mfg Capacity No. Compartments .� PKG. TREATMENT PPT. ❑ it i Method of Disposal Distance to nearest: Well Foundation Property Line ri LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .,; h SEEPAGE PITS ❑ Depth it Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." e' The applicant n1pst 9all f II required inspections. Complete drawing onnreverse side. Signed X ��- �..ti Title: �1,�17�YL�.L _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ` u Area < Pit or Grout Inspection by Date Final Inspection by ill Date AMOY 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 60 ��A/pMOU}NT REMITTED CCK 4 RECEIVED BY { DATE (][� PERR�MIT"NO. + EH 13-24IREV.1/65) 4 /�`�� 7 o33jOl`ice 4V gU alL�'J] EH 1426 C.JV (1 1