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�t n APPLICATION FOR PERMIT � f� "j � 1 } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ` <br /> ns <br /> Telephone (209) 466-6781 Nov 1988 <br /> PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) PEWVFf I SEl&ICES <br /> Application is heteby 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 /> a/'r <br /> Job Address �-� City/ -� Lot Size . PM <br /> Owner's Name Address ��� r - �'Q�/�! Phone <br /> Contractor � ress l� License No. Phone? <br /> TYPE OF WELL/PUMP: NEW WE41 . WELL REPLACEMEIbT 171DESTRUCTION Q <br /> ._ <br /> PUMP-INSTALLATJON .- _-.SySTEIM SPAtR-❑ © FiER-C _y --- <br /> DISTANCE TO NEAREST: SEPTIC TANK _.�?Q_.---- SEWER LINES _ DISPOSAL FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ON5 <br /> ❑ Ind pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> p'Dumestic/Private D Gravel Pack © Tracy Type of Casing Specifications <br /> M Public f 3 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I rigation Approx. Depth l I Eastern Sud ce Seal installed by <br /> Repair Work Done Ll Type of Pump �. H.P. .A_/ State Work Done <br /> OF <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth 40, Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION f I (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 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <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 L Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 st call for all ired 'nspeptions. Complete drawing on re rsesid / <br /> Signed X Title: ( „, ., Date: <br /> FOR DEPARTMENT USE ONLY pj <br /> Application Accepted by Data ` / J Area O <br /> I <br /> Pit or Grout Inspection by Date Di'Z'w Final Inspection b IWAVIR 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 INFO AMOUNT DUE AMOUNT REMITTER CASH RECEIVED BY PATE PERMIT'NO. <br /> ♦ EH 1321[REV.t i k s i 4IJ 3159 <br /> EH 11-26 <br />