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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT REGEIVE'D 1601 E. HAZEL T ON AVE., STOCKTON, CA 3 1g8 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �NV�RONN,ENTAL HEALTH (Complete in Triplicate) QERM)T+SERVlCES 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. Q � Job Address (J d t�tsr'✓�] __. city/ ' r`' '�"� Lot Size PM 1� YL(`� LoGa1 Owner's Name 1��L Address n� JLL,-�-.Ll`< Phone Contractor `s Address 1 77 y &/A;d"'cense No.�_ :5-2 J Phone-0-59 YdW TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 31 DISTANCE TO NEAREST: SEPTIC TANK SEINER 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 I�Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth_ ❑ Eastern Surface Seal Installed by Repair Work Done X Type of Pump H.P. Stat Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') 0 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other i 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. 177) 'fit ' 4Method of Disposal Distance to nearest: Well Foundation Property Line r � f i LEACHING LINE ❑ No. & Length of linessj Total length/size FILTER BED t 1-1Distance to nearest: Well ., Foundation Property Line 4 • 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. 4 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 c ill for required inspections. Complete drawing on re side. I Title: _ ��2Signed / b OR DEPARTMENT USE ONLY f / Application Accepted by Date 6 � ` Area Pit or Grout Inspection by Date Final Inspection by Date 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 CASH CK RECEIVED BY DATE PERMIT'N0. + EH 13-24(REV.i/d 5) �' Q EM 7426 4VVV t