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I r APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECF,01 F-D., 1641 E. HAZELTON AVE., STOCKTON, CA SEP Telephone (209) 466-6781 PERMIT EXPIRES 1tYEAR.FROM DATE ISSUED:" '94\J1KOlNMENTA>} H£ALTY4 (Complete,in T.ipl.icate) pERMITISERVICES 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 Rules and Regulations of the San Joaquin Local Health District. s CitycJLot Size f PM Job Address _ Phone Address Owner's Namn4 — d c� ContractorAddress T License No.w.1—.5=6 Phoneme TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Y I 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 El Bottom ❑ Manteca Dia, of.�Well Excavation Dia. of Well Casing Type of CasingSpecifications t Domestic/Private ❑ Gravel Pack ❑ Tracy ❑ Public ❑ Other I. ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _—APP roz'. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 9 Type of Pump H p State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material iBelow 50') Ln TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [3 DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation wdI serve: Residence_ Commercial Other ►i ` Number of living units: Number of bedrooms ! Water table depth Character of soil to a depth of 3 feet: _mss SEPTIC TANK LlType/Mfg + �' capacity No. Compartments PKG. TREATMENT PLT. Q 1 t Method of Disposal ' t ( i Property Line Distance to nearest: Well Foundation P rtY F %--_ Total length/size LEACHING LINE ❑ No_& Length of lines i FILTER BED ❑ Distance to nearest: well i Foundation Property Line i •f s --.4.�...� I SEEPAGE PITS ❑ Depth ` Size I Number SUMPS ❑ Distance to nearest: Well j;sFoundation Property Line DISPOSAL PONDS ❑ i i1 I hereby certify that I have prepared this application and that the work will be done in qpcordance 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 lav s of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which This permit i.Mssued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call f r IL-required inspections. Complete drawing on arse side. Signed)( "ly' Title: Date:�. I FOR DEPARTMENT USE ONLY 7 Date Area Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: 1 ❑ Stk 466-6781 LJ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY - DATE PERMIT"NO. ' INFO + EH 13-24(REV.1/6 5) EH 1426 Q L.