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APPLICATION FOR PERMIT #31F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 1601 E. HAZEL T ON AVE„ STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDV AUG 3 A 1988 <br /> (Complete in Triplicate) te�aa``T{y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th i�� iT�w15g141ication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th u1�If�9 �Rfif��f San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> Owner's Name �-"�z^' J2"�q-1 •r i Fels�5�o--! -!� "d" - . Phone " 7 <br /> Contractor n _ I Address License Nol Z3 2 3 Phone/46­�4 <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 /> r: <br /> INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom�'-. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ,,❑ Tracy i Type of Casing Specifications <br /> 11 Public ❑ Other j n Delta Depth of Grout Seal a Type of Grout <br /> r f a ! <br /> f 44rigation — w —.-Approx. Depth t+,Eastern S riace Seal Installed by 51 <br /> � <br /> Repair Work Done 2- Type of Pump H.P. State Work Done <br /> -Well Destruction ❑ Well Diameter .e t Sealing Material (top 501 ° <br /> Depth Filler Material (Below 501 �� r <br /> TYPE OF SEPTIC WORK: NEW INSTALI:ATiON I 1 Rti'AIRYAQDITION 1.1 *'DESTRUCTION I I (No septic system permitted if public sewer is <br /> -...-. .- --=available-within-200 feet.) <br /> Installation will serve/: Residence_ Commercial_ Other - <br /> . i <br /> Number of living units: Number of bedrooms <br /> Character of soil to i depth of 3 feet: Water table depth <br /> SEPTIC TANK © Type/Mfg Capacity - No. Compartments <br /> PKG. TREATMENT PL. ❑ Method of Disposal <br /> r r <br /> Distance to nearest: Well Foundation Property-Line <br /> ~ LEACHING LINE ❑ No. & Length of lines I Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation .Property Line <br /> r <br /> d f <br /> SEEPAGE PITS I i Depth Size Number. <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I 1,ave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations o the San Joaquin Local Health Di§trict. <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in skh 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 applica muscall for z required inspections. Complete drawing on reverse side. 1 <br /> j Signed X t r" N�-' ' �✓ f - Title: ']Date: / <br /> I <br /> FOR DEPARTMENT USE ONLY. <br /> Application Accepted by -C fJ Date �l __ Area <br /> Pit or Grout Inspection by bate Ficial Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 1 ❑ 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 AMOUNT DUE AMOUNT REMITTED iASR` RECEIVED BY DATE PERMIT NO. <br />` r INFO <br /> a e -� <br /> +.E441 3-24 I REV.i i x 51 <br /> EH 14-28 <br />