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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT D �� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2 1 1988 <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 hereinlesritiedhiS ilpplication 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. p Q <br /> Job Address. 7 ! D, 1�ta„+s.� 1 City­___ <br /> Lot Size PM <br /> r7 Y 3 5` �e.tel:a <br /> Owner's Name Address n� hone <br /> Contracto Address �License EYo. t� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 'PUMP INSTALLATION SYSTEM REPAIR ❑ 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 /> Domestic/Private ElGravel Pack ElTracy Type of Casing Specifications <br /> 171 Public ❑ Other C Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Depth I I Eastern l/Surface Seal Installed by <br /> ,f � _ <br /> Repair Work Done ❑ Type of Pump _ H.P. I/1. State Work Done 1V <br /> Well Destruction - ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION l I DESTRUCTION { I (No septic system permitted if public sewer is <br /> available within 200 feet.] W <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 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> � I <br /> LEACHING UNE ❑ 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 Ll Distance to nearest: Well Foundation - Property Line " <br /> DISPOSAL PONDS FI <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 /> " .Hnme 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 m st call f inspections. Complete drawing o reverse side. ` <br /> Sigma Title: Date:lO"I <br /> FOR DEPARTMENT USE ONLY . <br /> ~ Application Accepted by Date D N Area <br /> Pit or Grout Inspection by Date 'Final Inspection by Date1�3 u , <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK f RECEIVED BY DATE PERMIT N0. <br /> -EH <br /> EH14-zaIREV.titt5l <br />