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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE. STOCKTON CA <br /> Telephone (209) 466-6781 AUG 9 1988 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENViROMENTAL HEALTH <br /> li $ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereinFd RWb1$A on is <br /> 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 <br /> Local Health District. <br /> Job Address L,X`' l � }- - & City Lot Size PM <br /> 4 i . <br /> Owner's NamAddress Phone <br /> � � ` License <br /> Contract Address o L , ,License Evo 3 Phon T <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. s PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �4Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public Cl Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. .....______ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIRIADDITION 1 1, DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms_ `L. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> � e <br /> Distance to nearest: Well 'Foundation Property Line <br /> LEACHING LINE'7­ ❑ No. & Length of lines —.Total <br /> BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size f Number t <br /> SUMPS ❑ Distance to nearest: .Well .v .Foundation ` Property Line - <br /> DISPOSAL PONDS ❑ 4 ' <br /> 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 <br /> rules and regulations of the San Joaquin Local Health Diltrict. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant must a for �reqed inspections. Complete drawing on reverse side. ' <br /> �Signe X� Title: Date: <br /> RrbEPARTMENT USE ONLY A <br /> Application Accepted by - � Date Area <br /> j <br /> Pit or Grout Inspection by Date Final Inspection by-�`1 / Date <br /> . .. <br /> Additional Comments: <br /> ❑ Stk 466-6781 .❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk., CA 95201 <br /> FEECK 11 <br /> iNFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY _ DATE e PERmi-r No. <br /> 4 ..EH;: Ipsv.,,KS� �,5. ; :. 11 loo <br />