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APPLICATION FOR PERMIT <br /> a ' SAN JOAQUIN LOCAL HEALTH DISTRICT pAYMNT <br /> 1641 E. HAZE.T ON AVE., STOCKTON, CA R ECRI VED <br /> Telephone 12491 486-6781 <br /> ,PERMIT EXPIRES 1-YEAR FROM DATE ISSUOPT 18 1988 <br /> (Complete in Triplicate) ENV1� application is <br /> � ��n ed. This <br /> g� of the San Joaquin <br /> Application is hereby made to the San JoIqOn djrcianHe No.549 far sewage or ealth District for a permit to <br /> 1862 for cwelVpump at N� JII <br /> made in compliance with San Joaquin County <br /> Local Health District. I ' <br /> r / tot Size PM <br /> City <br /> Job Address <br /> i1 <br /> Phone <br /> Address <br /> Owner's Name <br /> fit/ T /�f,/Q¢1�Phone - Z'_ <br /> 5 Address <br /> Contractor ®OR �,�License No.. <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> OF WELL/PUMP: OTHER 1-1PUMP iNSTALIATION, ��,C 9 L YSTEM REPAIR ❑— _ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> INTEIVLSEf]USE , TYPE OF'WELL ' TROBL_�EM AREA YCONSTRUG710N SPEC-1FICATiONS Dia. of Well Casing <br /> f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ` Specifications <br /> D Tracy Type of Casing <br /> �%DomesticlPrivate ❑ Gravel Pack Depth of Grout Seal Type of Grout <br /> C1 Other her 11 ❑ Delta _ <br /> F ("1 Public [. S rface Seal Installed by <br /> I 1 trri ation- —_Approx. Depth 4 I Eastern <br /> g f ;i �f7 State Work Done <br /> ' e of Pum <br /> Repair Work Done ❑ Type p H.P.Sealing Material (top 501 lj <br /> Well Destruction ❑ Well Diameter �—•-�- Filler Material (Below 50'7 � [3 <br /> y1 Depth <br /> TYPE OF SE TIC WORKS NEW INSTALLATION I REPAIRlADDITION I ! DESTRUCTION I ! aNailabptic SYine2(101ee1tjed if public sewer is <br /> Other�- <br /> I stallaltion will serve Residene r Commercial V <br /> I <br /> NumbeFjofiliving units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mlfg Method of Disposal <br /> [ PK6. TREATMENT.PLT.-[d...---.—•--�i---- Property Line <br /> if [J _ iDis�anee.to nearest: Well Foundation <br /> 7 [ <br /> •� Total length/size <br /> LEACHING LINE C! No. & Length of lines Property Line <br /> L Foundation <br /> !'�' ❑ Distance t'6;nearest: Well <br /> FILi ER7 <br /> I 5iz Number <br /> SEEPAGE PITS 11 Depth Foundation Property Line <br /> Y� <br /> I SUMPS"�/T Ll Distance tol nearest: --- <br /> a,..-..w�DI�POS7�L'PONDS"^"' 0 :.` <br /> I he' certify that I have prepared this i application land�that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> e <br /> rulds and regulations of the San Joaquin'JL caLkdealth Di§trict. <br /> I Horne owner;or licensed agent's signature certifies the following: "I certify that in the per <br /> of the work for which this permit is issued, I Sha not <br /> or <br /> signature <br /> employ any person in such manner as to become subject to workman's compensatpiOn laws of California." Cpntracoi$Ub9lect to workmant!s9ompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons <br /> tion laws of California." h <br /> Th applican> I or II raquir d' tions. Complete drawing on reverse side. / <br /> i Title: Date: ` <br /> Sighed X i <br /> j FOR DEPARTMENT USE ONLY <br /> 1 s Date Il Area <br /> Application Accepted by /l-3 <br /> ` Final Inspection by Date <br /> Pit Pr Grout inspection by <br /> Bata � <br /> �ditional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71014 ❑ Tracy 835 6385 <br /> vironmental Health p4r ittServites eo k.�Hazei*AAS e., P.O. Box 2009, Stk., CA 952011 <br /> Applicant - Return all copies to: EnC RECEIVED BY PATE PERINIT"NO. <br /> -- - `T—FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO ©� 07 <br /> +.EH13-24(REV.�iasY �S <br /> EH 1416 <br />