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APPLICATION FOR PERMIT y� q <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA D y <br /> t <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE `U 19 1989 <br /> i'. (Complete in Triplicate) <br /> Application is hereby made to the SanJoaquin Local Health District for a permit to construct and/or install JXARq ir1 t1 ibl'fJ`4A$plication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/purtip and the FUR$MAERMIGEShe San Joaquin <br /> Local health District. .:. <br /> . 'IQa� l <br /> Job Address _ City Lot Size PM <br /> } <br /> Owner's Name ddress + Phone v 3 r' <br /> Irl 7V <br /> Contractor _Address _% "--�� kill;, <br /> l;, License No/ 23 3 Phone& <br /> /W <br /> TYPE OF WELL/PUMP: NEW WELL ❑ '',WELL REPLACEMENT ❑ DESTRUCTION EI ` n <br /> PUMP INSTALLATION I SYSTEM REPAIR ❑ OTHER ❑' �! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. PROP. LINE <br /> fFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (� <br /> R: INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ~,t <br /> ❑ Industrial ❑ Open Bottom [] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> W'bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public f1 Other ❑ Delta Depth of Grout Seal Type of Grout-- <br /> I <br /> rout I t Irrigation _-Approx. Dept I I Eastern Surface Sea-1 Installed by <br /> Repair Work Done Com" Type of Pump H.P, State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth tFiller.Material (Below 50') 1 <br /> ` TYPE OF SEPTIC WORK: :NEW.INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION ! I (No sept7kt <br /> rmitted if public sewer is <br /> _ r availableeet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br />'r .,„—Character of soil to a depth of 3 feet Wpth, <br /> f --,SEPTIC TANK t:-•❑y-.Type/Mfg. i Capacity I Noents} .:»w �_;.� _ ._ �� MeosalPKG. TREATMENT PLT.❑ ""� ' """" r""� ^---Distance to nearest: WelE FoundationProperty. <br /> LEACHING LINE ❑ No. & Length of lines l Total length/size <br /> FILTER BED ❑ Distance rto nearest: Well 1 Foundation ."' Property Line <br /> SEEPAGE PITS 1-1 Depth Size Number <br /> SUMPS ❑ Distance�to nearest: Wali 4 _ Foundation f.- Property Line <br /> DISPOSAL PONDS ❑ <br /> is <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. J: a <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 df California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the w 6rk for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m cat) r all required ' pections. C plate drawing o"2�1 <br /> verse side. — <br /> Signed X e: Date: G..- J 2�� <br /> FO DEPARTMENLY <br /> Application Accepted byDate Area <br /> oh <br /> (, <br /> Pit or Grout Inspection by Date Final Inspection by Date b <br /> Additional Comments: <br /> ❑ Stk 466-6781 L1 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> r.EH 13-24MEV.I/rt5) _aI_55 L.10 _� <br /> EH N-28 <br />