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APPLICATION FOR PERMIT PAYMENT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' RECEIVED <br /> 1601 E. HAZELTON AVE., STOCKTON, CA NOV 17 1988 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .ENVIRONMENTAL HEALT14 <br /> (Complete in Triplicate) PERMITISERVICES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address /l7� G � J� � City Lot Size PM <br /> Owner's Name flt aM_��LGLO�-' Address Phone <br /> Contractor 46 AAA tzI Address&27---V 1 ���:/ �License No. Phone 23`' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X <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 /> 4 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications _ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Irri ation <br /> 9 ---Approx. Depth El Eastern Surface Seal Installed by <br /> Repair Work Done L Type of Pump, 4 H.P. , —�>State Work Done.6, _A s <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 G <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments -1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 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 applicant must ca r all required inspections. Complete drawing on rp �rse side. <br /> Signed X Title: EY/31�d. Date: _ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date - Area ` O <br /> Pit or Grout Inspection by ate Final Inspection by Date <br /> Additional Comments: <br /> ❑ 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH <br /> + EH 13-24(REV.1/95) <br /> EH 14-26 <br /> I <br />