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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZEL T.ON AVE., STOCKTON, CARECEIVED <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `QCT 2 , 1988 <br /> (Complete in Triplicate) <br /> ��R��r�+ STH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work e i ation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and er Joaquin <br /> Local Health District. <br /> Job Address CityL-eL Lot Size PM <br /> �.r r w <br /> Owner's Name 40!�: Addressi��F <br /> h e S p� <br /> Contractor's Name License No. hone 31 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ZSr4 - SEWER LINES e!!2W7 — DISPOSAL PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !/ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a Dia. of Well Casing OOW <br /> ❑ Domestic/Private V Gravel Pack ❑ Tracy Type of Casing._` PPM . Specifications <br /> j )4 Public ❑ Other ❑ Delta Depth of Grout Seal /W Type of Grout <br /> ❑ Irrigation OWApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> I Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION ❑ (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 <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. El Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> l SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 District. <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 applicantrp t call for 911 required inspections. Complete drawing on reverse side. <br /> Signed XD . <br /> Title: <br /> i FOR DEPARTMENT.USE ONLY f <br /> i Application Accepted by Date Area ` <br /> .Pit or Grout Inspection by ?TMDate 0- Final Inspection by Date <br /> ! f <br /> Additional Comments: �–�°�� _ <br /> ❑ Stk 466-6781 Q Lodi 3621 ❑ Mantgo 823-7104 ❑ Tracy 835 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO 1�AMOUNT DUE AMOUNT/REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +EH 13-24 IREV.10!83) . {/// <br /> EH 1428 VV <br />