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I _A-L � APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZE LTON AVE., STOCKTON, CA Telephone (209) 466-6781 UEC 12 1988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH Pereind Srl�Vl Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d scn ed. 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. Job Addressi r AA. City - Lot Size PM Owner's Name ye : Address SCJ UJ, (�``C __ rl�� Phone G�r/C / C E ,`'�,-- Contractor L.('✓ Address a -� Q License No. Qeo Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION, SYSTEM REPAIR [J OTHER DISTANCE TO NEAREST: SEPTIC TANK WER 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 C1 Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depths of Grout Seal .Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern §urface Seal Installed by Repair Work Done It Type of Pump H.P. State Work Doney ItW f Well Destruction ❑ Well Diameter Sealing Material (top 501 J • Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -available within 200 feet.) r 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 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 ❑ Depth Size Number SUMPS ❑ Distance 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- tion laws of California." The applicant must call f all required inspections. Complete drawing on verse side. Signed Title: Date: /.2j aI., _ FOR DEPARTMENT USE ONLY Application Accepted by Date A� Area 0 CfL Pit or Grout Inspection by Date Final Inspection by 1er`� _ Date J- _ 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 C1A* RECEIVED BY DATE PERMIT'NO.' SH +EH 1324[REV.1/s 5> 43S-E- . 'l_ o"a 01� 7[�- I �. ��^`' .�✓'�I EH t42B ti/`J V� l �^c� i