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4 APPLICATION FOR PERMIT PAYMENT 1601 JOAQUIN LOCAL HEALTH DISTRICT RECEIVED i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 MAY ,. PERMIT EXPIRES 1-YEAR FROM DATE ISSUED y 1t , (Complete in Triplicate) i '�pl NME AHA kT.fhe San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ma 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. y� Job Address lP0 City Lot Size PM p. —Phone Owner's Name l /y t 24 f�- Address ' 10/J , ��}��+ i Contractor% . 6ro,5 Address r� oz-s _ �` Lins too. tizcLf��-_Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION C] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ —., DISTANCE TO NEAREST: SEPTIC TANK n4 _ _ SEWER LINES DISPOSAL FLD.�L�PROP. LINE ,_. ., FOUNDAT=ION.. °-`--� AGRICULTURE WELLOTHER WELL -_.PkTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �i ❑ Industrial LI Open Bottom Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing _ Specifications _ �] 1-1 Public ❑ Other n Delta Depth of Grout Seal f �� Type of Ci Tu I I Irrigation - _..Approx. Depth I I Eastern Surface Seal Installed y' / Repair Work Done fU Type of Pumpf H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth 3 Fillet Material (Below 50'1 r TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I I DESTRUCTION l I Wo septic system permitted if public sewer is r available within 200 feet.) 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 i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t 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 I'I Depth I Size Number ! SUMPS Ll Distance to nearest: Well Foundation Property Line ._. DISPOSAL PONDS_-,=_Er r 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 Di1trict. 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." w The appli nt st call for all r fired nspections. Complete drawing on(frrebe�rf/se/side. Q Signed X Title: +�• f� Date: 7 u e ' I FOR DEPARTMENT USE ONLY i 1 Application Accepted by Date Area Pit or Grout Inspection by/J Date Z Final Inspection b Data i t SID z i Additional Comments: V ❑ Stk 466-6781 ❑ todi 369-301 ❑ Manteca 823 04 ❑ Tr cy 835-6385 dr Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .01 1 i FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. i INFO - 4'EH 13.24 IREV.i/n 5lJ 415 L)