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/� • APPLICATION FOR PERMIT • <br /> rIVED <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT R l kyr <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ll• <br /> Telephone (209) 466-6781 DEC 6 1989 <br /> CO) <br /> 3/� PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDENVIRONMENTALHEALTH <br /> (Complete in Triplicate) PERMIT/SERVICES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <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 2040 W. Washi ncttnn Rt rppt City St nnlrtnn Lot Size PM <br /> Owners Name Supply Address Phone <br /> Contractor Spectrum Address 2825 E. Myri-.t p License No. 512268 Phone <br /> TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ h\VJ <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 171C PS Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SCH 40 PVC Specifications <br /> r-I Public ❑ Other ❑ Delta Depth of Grout Seal 10 ft Type of Groutrampnt /hpnt Or <br /> I I Irrigation 2,�-.Approx. Depth I I Eastern Surface Seal Installed by cfrpn+ piiMp <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <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 /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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 regulations of the San Joaquin Local Health Di?:trict. <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/S <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature 1 <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 applic m t call for all requir i actions. Complete drawing on reverse side. q <br /> Signed X Title: ���• Date: <br /> OR FITMENT USE ONLY <br /> Application Accepted by --1�—{ GL Date/ S" Area !Z9 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 <br /> INFO RECEIVED BY /f DATE PERMIT'NO. <br /> a EH 1}1/IREV.1/x51 <br /> 13-24 <br /> EH <br />