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APPLICATION FOR PERMIT <br /> PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICTS �E}i1T <br /> RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA R E C <br /> j. Telephone (209) 466-6781 <br /> NOV�J- 1 7 1988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG0 lg " <br /> SAN JOAQUIN WuNTY �: (Complete in Triplicate) ��Tu " <br /> PUBLIC H EALTF 4 RVICES �� �c�i}p 'Cffi�a'pplicatian is ' <br /> NVIR NM <br /> .�lJt9AWaquin Local Health District for a permit to construct and/or install a w d the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ru <br /> Local Health District. <br /> t <br /> � ` �fj}/�J4 City Lot Size PM <br /> Job Address <br /> Owner's Name i] Address <br /> ra <br /> / �'..� Address <br /> License NA-", — Phone )�� <br /> Contractor�' !:e��'�'°' <br /> WELL REPLACEMENT <br /> El DESTRUCTION ❑ <br /> TYPE OF WELL:/PUMP: NEW WELL„�� _ <br /> _71 P.U9P�-INSTALL A1t()N.❑ .-_ .: <br /> SYSTEM REPAIR`❑{a - ,..OTHER,.❑-2� <br /> r ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> �} r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p Dia. of Well Casing �O <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L <br /> Type of Casing Specifications <br /> ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Type of Grout <br /> * Public S 1 Othhr Cl Delta Depth of Grout Seal <br /> E I Irrigation .✓Approz Depth I 1 Eastern Surface Seal Installed by <br /> III H.P. StateWojk Done <br /> — i <br /> Repair Work Dane ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material flop 50'1 <br /> a Depth 1 Filler Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION l I DESTRUCTION 1 1 (No septic syste <br /> c thin 200 feet.)ied if public sewer is <br /> available l <br /> Installation ,Dill serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms ' <br /> I = Water table depth <br /> . <br /> Character d soil to a depth of 3 feet: <br /> SEPTIC TANKh; ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. 1-1Method of Disposal <br /> 'i�' Distance to nearest: Well Foundation 'Property Line <br /> k Total length/size <br /> k LEACHING LINE ❑ No. & Length of lines <br /> t <br /> FILTER BED El Distance to pearest: Well Foundation Property Line,! <br /> SEEPAGE PITS I I Depth Size — Number .� <br /> f _ Foundation line <br /> p o <br /> SUMPS Ll Distance to nearest: Well' <br /> DISPOSAL PONDS ❑ <br /> I 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 redulations of the San Joaquin Local Health Dltrict. <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 /> ' � <br /> The applica t m st c"r all re fired ins c' S. mplete drawing onreverseside. � <br /> yy, Title: �' jrJ1/ Date. <br /> I Signed X r z �� <br /> I F EPARTMENT USE ONLY l _ <br /> Date + Area <br /> Application Accepted by — <br /> Pit or Grout Ilnspection by Date�� 2/ Final Inspection by Date <br /> Additional Clmments: 3 2- �� 1� <br /> F ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Mant ca 823-7104 ❑ Tracy 5-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Smices 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> kFEE AMOUNT DUE117!D CASHRECEIVEQ BY PATE PEftM1T NO. <br /> INFO 1f 1EH 13-241REV.I/k 51 �p� )5; 11-17 45 <br /> ? EH 14-2e 4 <br />