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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E..HAZELT ON."AVE:,,STOCKTON, CA ECEVED Telephone'{209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU ; <br /> i (Complete in Triplicate) DEC) 6 3989 <br /> �PWROM* ir'�! sc rAj 't+P.P.`J cation is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or "�j t t e San Joaquin <br /> made in compliance with San Joaquin County Ordinance 549 for sewage or No, 1862 for well/pump andrHrerfitft a�4tl�R�S-? <br /> Local Health District. <br /> T C City ' Lot Size PM <br /> Job Address -- 1?Q,dnK 4,9039 <br /> ' } Phone 3 <br /> Owner's Name Address <br /> i <br /> Contractor e.V W� Address <br /> License No. �Phone I <br /> TYPE OF Wim!/PUMP: NEW WELL 1-1WELLREPLACEMENT © DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR 1w._� OTHER .0 <br /> T SEWER LINES DISPOSAL FLD. PROP, LINE s <br /> DISTANCE TO NEAREST: SEPTIC TANK ti <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> E=.stic <br /> trial ❑ Open Bottom ❑ Manteca .Dia. of Well Excavation <br /> Type of Casing Specifications <br /> �tr El Gravel Pack ❑ Tracy Type of Grout <br /> (-I Public 171 Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation <br /> _ Approx. Depth l I Eastern Surface Seal Installed by <br /> e of Pump H:P• State Work Done <br /> Repair Work Done & typ <br /> ' Se ling-Material_ftop-50'1�, <br /> Well Destruction. D._ Well Diameter.,_ r— t <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION [.0.yailabptic ssystem <br /> permfee itted if public sewer is <br /> I <br /> Installation will serve: Residence_ Commercial— Other i. <br /> Number of living units: Number of bedrooms l;T ,,:.. <br /> I+rUater table depth <br /> Character of soil to a depth of 3 feet: s rt <br /> SEPTIC TANK ❑ Type/Mfg I � Capacity 5 ' No. Compartments (UJ <br /> { Method of Disposal <br /> PKG. TREATMENT PLT- ❑ r <br /> Distance to nearestf Well ''� R Fo ndation -4 Property Line rhA <br /> f + Total length/size <br /> LEACHING LINE ❑ No. & Length of lines, , <br /> FILTER SED ❑ Distance to nearest: '" Welf - i Foundation Property Line <br /> SEEPAGE PITS I'] Depth Size Number <br /> SUMPS <br /> Ll Distance to nearest: Well * Foundation Property Line <br /> .r <br /> DISPOSAL PONDS ❑ <br /> that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application 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, 1 shall not <br /> I'M <br /> anif <br /> ch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> ceRifies thollowing:' certify that int perform of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws California." <br /> The appli ant call or all qu' t o verse side. <br /> Signed X <br /> Title: / Date: �a <br /> OR DEPARTMENT USE ONLY / ! <br /> Date ~� Area <br /> Application Accepted by / <br /> Data <br /> Pit or Grout Inspection by Date Final inspection by <br /> � <br /> I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 fl 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 /> [=FEEAM�OUNTCK RECEIVED f3Y DATE PERMIT"NO. <br /> REMITTED GAS ']'�� <br /> +.EH 13-24(REV. <br /> { EH 14-26 - <br />