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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PAYMENT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 AEIV <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED SAN 2 j 1990 <br /> (Complete in Triplicate) SAV JOA UIN CQLA,`Tr'Y' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the SifearioR� is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1B62 for well/pump and the AWW9il in <br /> Local health District. <br /> Job Address City f- /L4,41.t Size PM <br /> Owner's Nam Address U M � Phone <br /> C /— Phone <br /> Contractor Address ��P� License No <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONK 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 /> XAomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public Cl Other t ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I Irrigation _..Approx. Depth 13 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump 5,, _ H.P. _YZ- _ State Work Done lu <br /> v . <br /> Well Destruction CI Well Diameter Sealing,Material Itop.50') <br /> Depth Filler Material (Below 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION l I DESTRUCTION I I Mo septic system permitted if public sewer is <br /> available within 200 feet.) -3 0 <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 /> w <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Fou rZds ion Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL PONDS J" 1-1- <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 taws, 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 shali employ persons subject to workman's compensa- <br /> tion taws of California." _ <br /> The applicanry us call-for-all req it i coons. Complefe drawing on rovers side �. .if " <br /> Signed X ` s Title: f !/rte c t�4f� _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �� Date Area <br /> Pit or Grout Inspection,by Date Final Inspection by Date-/� <br /> Additional Comments: / i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <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 CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24(REV.t/s 5) <br /> EH 14-26 '7 +' <br />