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9"6EAPPLICATION FOR PERMIT CI v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT AUG O 1 1990 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ,6\ Telephone (209) 466-6781 ENVIRONMENTAL HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVIO`S <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 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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address A.77 _78_`�Ao � � City _ of Size PM <br /> Owner's Name/3 O ��ress a1p-1 �4A a � z Aw- —L4-=t-Phone <br /> - <br /> Contractors Address Q .5301ficense Phone ~S�! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR Cd"` 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 /> *omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ('1 Public " Other ❑ Delta Depth of Grout Seal Type of <br /> I I Irrigation ___.Approx. Depth It Surface Seal Installed by <br /> Repair Work Done � Type of Pump H.P. 1--- State Work Done I n <br /> Well Destruction 11L <br /> Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other O <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK El Water table depth Type/Mfg Capacity Water <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 0 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size - <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ Cn <br /> 1 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 c 1 r all required i spections. Complete drawing on rev rse side. <br /> Signed X a <br /> Title: Date: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by Date Area / <br /> Pit or Grout Inspection by Date 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 <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24(REV.i i x 5) <br /> EH 14-2e 1-3r-90 921-240Q5 <br />