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-, ►}� y APPLICATION FOR PERMIT <br /> "SAN JOAQUIN LOCAL HEALTH DISTRICT A <br /> r 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Teleph6he (209) 466-6781 , <br /> J <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,JUN 71989 <br /> !Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workhheiin_deser.ibed;=This�applRc1�tion is <br /> made in compliance with.San Joaquin County Ordinance No.549f or sewage or No. 1862 for well/pump and the Rules and Regulations`ofrthe_5an Joaquin <br /> Local Health Districi.--. <br /> `�� r– } <br /> Job Address 15 tl /0 7 City' .Lot Size PM <br /> Owners Nam .MhA + I Address �/ �– �/ Phone <br /> r1 <br /> J �Contractor icense No. Phane' � <br /> TYPE OFALLUP WP: 7 NEW WELJ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REP�IR ❑ O HER'❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK I/ -SEWER LINES , �'�- DISPOSAL FLD. --PROP. LINE ! = <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS &0 <br /> INTENDED USE TYPE OF WELL` PROBLEM AREA CONSTRUCTION SPECIFICATIONS, <br /> ❑ Industrial ❑ Open'Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy I Type of Casing `�+ Specifications <br /> ['] Pub is ❑ Other l 1 Delta Depth of Grout Seal T Type of Grout . <br /> rrigalion -"Approx. De th l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump l H.P. 45 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 1 <br /> Depth Filler Material (Below 501 �' 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR1ADDITION I I G DESTRUCTION I I (No septic system permitted it public sewer is 1 s <br /> - -:` _ available within 200 feet.] <br /> Installation will serve: Residence_ Commercial— Other 'Q ) <br /> Number of living units: Number of bedrooms <br /> - <br /> Character of soil to a depth of 3"feet7' Water table depth- <br /> SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE, ❑k No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well. Foundation Property Line <br /> —­SEEPAGE PITS. I IDepth Size Number <br /> SUMPS AL1 Distance to nearest: Well Foundation Property tine <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 law's; and <br /> rules and regulations of the San Joaquin Local Health Dilstrict. <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 mus c for all r quir d nspe tions. Complete drawing on re se side. <br /> Signed X Title:[-Zf Date: <br /> FOR DEPARTMENT USE ONLY <br /> -�Application Accept/dby _ Date Area <br /> A y E <br /> Pit or Grout Inspection by Date Final Inspection by /2;11Date c f <br /> Additional Comments: x .L Cd l•'� ��d <br /> 0 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 95201FEE <br /> f/ <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> ASH <br /> +rEli 13-21[REV.i/n5) f d�« <br /> c <br /> EH 11-28 v 1 ��-' 1 Q k <br /> P <br />