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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F­�.,, F1',% <br /> A <br /> 1601 E. HAZELTON AVE., STOCKTON, CA LM <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 4 11989 <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wFl"3AWAIld Pit!TI&ELilplication is <br /> ,P <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 CitVIkinch Lot Size PM <br /> 3ftr"e-- <br /> Owner's Name_':�Oh W MAA�l Address Phone <br /> WAIeR— <br /> ContractormpoenclAid t� g&jaAddress-q/P_0 License No. F`hone.2?1L_9_&D <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION-KRq1A04W,1k SYSTEM REPAIR 0 OTHER 0 <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'-1tv'PROBLEM-AREA -CONSTRUCTION-SPECIFICATIONS - � ' - -_ <br /> ❑ <br /> CONSTRUCTION-SPEC-IFICATIONS-- <br /> F] industrial 0 Oper? Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> -estic/Private D Gravel Pak0-Tracy '_ripj_._0f Casing' Specifications <br /> -FI-Delta--- `De'Ptho(Grc�ut'Seal"_ Type of Grout <br /> Ir 01Pu b t [- Other_1 <br /> i I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done Ll Type of Pump StA-b H.P. I .. __ State Work Done Rk 0WLd OW_A� <br /> Well Destruction El Well Diameter Sealing Material (top 501 A 31+94eaO <br /> Depth — Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— dom`me__rcfaI'_­7 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 El Type/Mfg Capacity— No. Compartments _J <br /> PKG. TREATMENT PLT. 171 Method of Disposal <br /> I'Dista`i1i;6 ff 6&ar69t"- Well Foundation— Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation— Property Line <br /> SEEPAGE PITS I I Depth _Size Number <br /> SUMPS L-i Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDSn <br /> I hereby certify that I have prepared this applid-ation 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 t s nia." <br /> p <br /> The plic -for-at pal inspections. COMPI awen <br /> Sign X Title: <br /> Date: <br /> R DEPARTMENT USE ON <br /> Applici n Accep, <br /> Z,ep Date Area <br /> Pit or Grout Inspection by ate— Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 El Lodi 369-3621 0 Manteca 1323-71104 El 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-NO. <br /> INFO CASH <br /> ♦ EH13-24[REV,I/B 5) <br /> 426 <br /> EH I C=!SCn,_ �0 <br />