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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT R E C E I V E D 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISVP_ .0 W (Complete in,Triplicate) •ONMENTAI- HEALTH T9 M" v. PERMIT/SE SRVICES Application is hereby made to the San Joaquin Local Helth 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. 1.662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.' .lob Address r 1,�.� b V CityAoidk Lot Size -PM Owner's Name o P o'a Address OU - G ,, r t PF / �rPv''Jryvc9q yS3� Contractor r— 4 Address 6 G4 �.,R S. License No.wwf- 2�Phone�y� ^oy p 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 Q Open Bottom 1-1MantecaDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public K Other W)vvl s1,4�❑ Delta Depth of Grout Seal Type of Grout # ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed.by Repair Work Done ❑ Type of Pump H.P. State Work D ne_ I� Well Destruction $t Well Diameter 9i-4 Sealing Material (top 50') 0 'Ai 0— tyA fnr Lra%4—or Depth s f`"r'^ Filler Material [Below 50') v r iTYPE OF SEPTIC W K: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NosejTtic system permitted if public sewer ilable within 200 feet.) , Installation will serve: Res nce— Commercial— Other Number of living units: mber of bedrooms Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. Ll Method of Disposal s - Distance to nearest: ell Foundation { Property Line f LEACHING LINE ❑ No. & Length of lin Total length/size FILTER BED ❑ Distance to ne st: Well Foundation Property Line SEEPAGE PITS O Dep size Number SUMPS ❑ istance 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- tioh laws of California." 0. tmehf 4 The applicant must call for all required inspections. Complete drawing er-rise-side. J Signed X r^ 1 A�r1r` 1� 4 � C- Title: t V POLO � ZS -�O�e �(s Date: 3 /� FOR DEPARTMENT USE ONLY Application Accepted by Date 14 03 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.,Box 2009, Stk., CA 95201 +� �aN o•. �:�e ��a wve� to �« l�µsati o� CuQw��B 14 1It's 18-s- I Fff- INFO AMOUNT DUE AMOUNT REMI D CASH RECEIVED BY DATE PERMIT NO. + EH1&241REV.ila51 EH 1428 �^�, d[}-