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^�. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT D � n <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> s Telephohe (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED AUG 2 91988 <br /> (Complete in Triplicate) HEALTH <br /> F Application is hereby made to the ENViROM <br /> San Joaquin Local Health District for a permit to construct and/or install the worKtrp�re� ENT P& 'pii`cSation is <br /> F 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 /> f` Local Health District. <br /> ` Job Address r w City Lot Size PM <br /> l Owner's Name Address i <br /> Contractor � — <br /> I �D� LL- ���Aress CD�� gyp/Phone f <br />' Address 1 License No, �a��� Phone r ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ <br /> PUMP INSTALLATION ,VPP419z-0 SYSTEM REPAIR ❑ OTHER ❑ <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom CJ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ,.Domestic/#Private 4 Gravel Pack L1 Tracy Type of Casing Specifications <br /> M Public Fil Other n Delta Depth of Grout Seal Type of Grout <br /> -_­ <br /> I I Irrigation Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work one ❑ Type of Pump -'J'021 H.P. c�! State Work Done erj <br /> Well Destruction Q Well Diameter Sealing Material Itop 50'} <br /> Depth Filler Material (Below 5o') <br /> TYPE DF SE TIC 1NORK; NEW INSTALLATION l l REPAIR/ADDIf7IDN f I <br /> I / DESTRUCTION I I (No septic system permitted it public �is --J <br /> � .available within 200 feet.! <br /> Installation will serve: Residence_ Commercial_ Other � ?INN <br /> Number of Iiving)i1-9its: _1— Number of bedrooms <br /> Character of soil-to a depth of.3 feet: :� Water table depth <br /> SEPTIC TANKC = <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT'PLT. F), S Method of Disposal <br /> i f t; Distance to nearest: Well ` Foundation Property.Line —^ <br /> LEACHING LINE ❑ No. & Length of lines F ^F Total length/size [� <br /> FILTER BED ! ❑ Distance to nearest: Well ` ndati..__w_________. _ Property Linef <br /> Foo undationi <br /> SEEPAGE PITS ✓ 11;l Depth r Size <br /> I �' Number <br /> SUMPS ❑;I Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS f ❑j I t <br /> I hereby certify that I'have Peparad this application and that the work will be done in a c�ordance witti San Joaquin county ordinances, state laws, and <br /> rules and req ulatior�v.of the2an Joaquin Local Health D�trict. <br /> Home owner or licensed ag i6t's signature certifies the following: y <br /> employ an r g: "I certify <br /> that in the rldrmance of the work for which this permit is issued, I shall not <br /> p y y person in such manner as to become subject to workman's compensalioTHaws.of_California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cer lfy 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 a require s. Complete drawing on revers side. <br /> Signed X Titfe: r— I 2 <br /> Date: <br /> FOR DEPARTMENT USE ONL <br /> Application Accepted by 0 <br /> Datac <br /> Area <br /> Pit or Grout Inspection by I Date Final Inspection by J <br /> I Date_ <br /> Additional Comments: ! <br /> t <br /> ❑ Stk 466-6781 ❑ L�di 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Rfeturn all copias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO LASS RECEIVED BY DATE PERMIT'NO. <br /> ..EH1 -21fREV.IiKsl l+�j\ fy/ ��.-7a <br /> EH 114-2B W ..O' LJT 1. r ff aVX i <br />