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4y' <br /> APPLICATION FOR PERMIT � <br /> C SAN JOAQUIN LOCAL HEALTH DISTRICT D <br /> t? 1601 E. HAZEL T ON AVE., STOCKTON, CA �titiv// <br /> Tele hone {209} 466-6791 <br /> p AUG 2 9 1988 <br /> PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED_ <br /> ` {Complete in Triplicate} ENVIROMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instalt the w(FEWIUOCnit'il410i,%application is <br /> made in compliance with Sari Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Loca( Health District. <br /> Job Address _._...... <br /> City.z*� ' _ Lot Size PM <br /> WAV' <br /> Owner's Name�`_� r ......'. Address _..........— Phone qzl _aer. <br /> Contractor ....,—Address— � Phone��o� License No. � (� <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ <br /> DESTRUCTION O <br /> PUMP INSTALLATION, t fZ� ZgT?SYSTEM REPAIR C OTHER 0 <br /> ,L,AC <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _....... DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ___ PITS/SUMPS <br /> -. ._...... -. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> -- -- <br /> 0 Industrial C Open Bottom 0 Manteca —Oia'of•Well Ezra-vation Dia. of Well Casing <br /> Domestic/Private O Gravel Pack C Tracy ( Type of.Casing_ ` .._ Specifications <br /> ("1 Public 'l Other Cl Delta } Depth of Grout Seal Type of Grout <br /> I I Irrigation .-__Approx. Depth, ;_!_Eastern •t t Surface Seal installed by <br /> Repair Work Done LJ Type of Pump H.P. _-�o�___ .._ State Work done Well Destruction G Well Diameter '=' Sealing Material (top 50') f 1���2_ 2 'w <br /> Depth ,r. Filter Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ; I REPAIR/ADDITION ; 1 DESTRUCTION I :,I No septic system permitted if public sewer is <br /> available within 200 feet.) r* <br /> Installation will serve: Residence — Commercial-_ Other <br /> Number of living units: ....— Number of bedrooms,.....___ _ <br /> i <br /> Character of sail to a depth of 3'feet: r Water table depth <br /> SEPTIC TANK 0 Type/Mfg r ' <br /> - Capacity No. Compartments -_ <br /> PKG. TREATMENT PLT. 0 ""% r <br /> •�'' � Method of Disposal .._. <br /> Distance to nearest: Well___ Foundation Property.Cine <br /> LEACHING LINE LI No. & Length of lines '' ':� ''•lTotal length;size <br /> ,. 7,4 <br /> FILTER BED D Distance to nearest: Well :Foundation -Property Line._ <br /> SEEPAGE PITS I : Depth _.._Size ..... Number <br /> - — <br /> SUMPS [.� Distance to nearest: Well _Foundation _._ : Property Line <br /> DISPOSAL PONDS ;_1 <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 Heatth District. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> �»-employany-person 4n-such manner-as to,become-subject•to workman's-compensat ion 4aws 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 applicant at quired jp e i Q`MPZ"`T,t,,: Date: <br /> ' awing on revs se side. <br /> Signed X <br /> DE-PIR USE 044 <br /> — <br /> Application Accepted by -- Date Area �✓ �.W <br /> Pit or Grout inspection by Date Final Inspection by �N Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823.7104 O Tracy a35-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED EY DATE PERiNtT'N0. <br /> INFO r CASH O. <br /> + EH 14.2grRIV.rik5r <br />