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APPLICATION FOR PERMIT <br /> _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTn <br /> 1601 E. HAZE T ON AVE:, STOCKTON, CA V o <br /> Telephone (209) 466-6781 J U N 71988 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIROMENoT�AL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ��� � is application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the u es and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City _ Lot Size PM <br /> Owner's Name z/)+Address Phone Qz <br /> Contractor g0*e- &/-j Address c-71_711 /ej!f2�0,,Af License No. 4469V6 PhoneT-a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION W 0,F��SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:SEPTIC TANK" SEWER LINES-� DISPOSAL FLD. 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 /> Xomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ("I Public f71 Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation --Approx. Depth I 1 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 50') ' <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200,feet.) P . <br /> I Installation,will`servei" Residence_ Commercial_ Other ' W <br /> + Numbe.r.of living units:. Number of bedrooms sd d <br /> Character of soil fo a depth of 3 feet: .=--Water table depth <br /> SEPTIC TANK >❑ Type/Mfg Capacity No. Compartments <br /> PKG-'TREATMENTPLT. ❑ Method of Disposal <br /> Distance to nearest:,,,, (Nell — Foundation- _ ,eroperty,Line t <br /> LEACHING LINE _❑ No. & Length of lines Total length/size r <br /> FILTER BED r ❑ Distance to nearest: Well Foundation Property Line <br /> ' SEEPAGE PITS l I Depth _ Size Number t f <br /> I, 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 $an Joaquin-county:ordinances, state laws, and <br /> rules and regulations of the San Joaquin-Local'"fiealth 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 /> r The applicant m required " ti s. Complete drawing on reverse si p. i <br /> Signed X Title: Date: <br /> ` FOR EkEPARTMENT USE ONLY <br /> Application Accepted by Date4Z3(_0-,W Area "► <br /> Pit or Grout Inspection by Date Final Inspection by Date, <br /> Additional Comments: OlInIRA <br /> ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Mante 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 /> i <br /> IEEE AMOUNT DUE AMrOOUNTrREMITTED CASH RECEIVED BY r DATEp PEpRMIT'NO. <br /> ♦.EH13-24IREV.t/Hsl 3J -�/v <br /> EH 14-26 <br />