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t APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 fQd4..n I PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. (Complete in Triplicate) ENVIRONMENTAL HEALTH DIVISION 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. Job Address � g.� Q �ZC7. City/i /_tel Lot Size PM Owner's Name t Address-Z7:0 6�12al Phone6&x 1 Contractor '. " Address - icense No.`/!� Phoned TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ^ ADomestic/Private ❑ Gravel Pack). ❑ Tracy Type of Casing Specifications U n Public P ❑ Other I . ❑ Delta Depth of Grout Seal Type of Grout _. p I I Irrigation -Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done IX• Type of Pump#!J__�&- H.P. / �� ___ State.Work Done {Nell Destruction ❑ Well Diameter " Sealing Materialltop 501 r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is I i = *— available within 200 feet.) Installation will serve: Residence ` Commercial_ )Other 00, Number of living units:, Number of bedrooms Character of soil to a depth of 3 feet: ! Water table depth,.,? SEPTIC TANK lj-Type/Mfg r 'F z Capacity No. Compartments' PKG. TREATMENT PLTr❑ / Method of Disposal Distance to'nearest: Well Foundation Property Line r p � LEACHING LINE ❑.., No. & Length of lines Total length/size FILTER BED ❑ Distance tolnearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll •Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that t 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." i The applicant Wst call f all required inspections. Complete drawing on reverse side. Signed X_V • - _ Title: Date: zf2 J�f � F09 DE RTMENT USE ONLY Application Accepted by Date < ff 1 Arna C Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 EI Manteca 823-7104 ❑ Tracy 835-6385 , Applicant - Return all copies to: Environmental Health Permit/Sarvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i 1 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, INFO + EH 13-24IREV.r/N5S EH 14-2e 1