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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP 2 U 19dd PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) NVIREON IMTE�NTA��//L((HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the-work herein descri ad T s applicatio ES 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 IDS SCA_V«%\0 AN-Q- City A0v1--_Lot Size PM K0 �1 4, Owner's Name �Cw�� Address Phon� L_�'1V�—� l 11 _ Contractor CJI`" 1 Address aLicense No.L y ,Q9 Phor� _ _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Si ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 �t L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat' n Dia. of Well Casing Gr 1 ❑ Domestic/Private )(Gravel Pack ❑ Tracy Type of Casing V Specifications 11 Public ❑ Other fl Delta Depth of Grout SealS*_-. Type f Grout- . I I Irrigation _.Approx. Depth I I Eastern Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ell Diameter Sepliing Mater'a1100 501 - V, ' ~ Depth �O� C FiM1er aaterr'al-IBefow 5Q'1 5z � TYPE OF SEPTIC RK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: R ' ehce_ Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3 fee . Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founda Property Line SEEPAGE PITS I I Depth Size bar SUMPS Ll 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requ'red ins ction Complete drawing on reverse side. c, Signed X v Title: Date: b FOR DEPARTMENT USE ONLY Application Accepted by Date Area lZaZA Pit or Grout Inspection by e F tion by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tra14 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 CK CASH RECEIVED BY DATE PERMIT'NO. • EH 13-24(REV.fix 5) EH 14-26