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- APPLICATION FOR PERMIT pA=yM` -14T <br /> SAN JOAOUIN:LOCAL HEALTH DISTRICT tC;F <br /> Iv <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 SEP 141987 <br /> 1PERMIT EXPIRES 7 YEAR FROM DATE ISSUED MENSAL HEALTH- <br /> .,Qf ,:x <br /> (Complete in Triplicate) ENVIRON <br /> Application is hereby made to the San Joaquin Local Health <br /> District 549 or fOsewage or r a permit <br /> No. 862 for well and/or <br /> pump install <br /> nd the Rules and rRegu�lat+�the San Joaquin <br /> _..made in compliance with San Joaquin County Ordinance <br /> Local Health District. of .r. ' <br /> t� ^ " Lot Size 5 rX 3� PM <br /> IL r C <br /> 76 <br /> Job Address _ F _ �5 <br /> Address off/ Phone <br /> 1, D� <br /> Owner's Name -� <br /> License No. Phone <br /> 27Q�� <br /> . Address - r , <br /> Contractor DESTRUCTION ❑ v� <br /> NEW WELL WELL REPLACEMENT ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> "PUMP INSTALLATION ❑D ' <br /> SEWER LINES --- DISPOSAL FLD. �� PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK - PITS/SUMPS (f , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C3 Industrial [I Open Bottom ❑ Manteca Dia. of Well Excavation ✓ Specifications <br /> Type of Casing <br /> �I <br /> Domestic/Private $) Gravel Pack JX Tracy Depth of Grout Seal 'Type of out <br />` ❑ Public ❑ Other f L3 Delta <br /> I <br /> El Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 50') <br /> Well Destruction [I Well Diameter <br /> Depth IOr Filler Material 'B 11 e 11 low 50'I <br /> ,11111 <br /> TYPEI'll I 11 O11 F S 11 EPTIC WORK: NEW IN57ALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ alvailabpelwi hm 20feet.)permitted if public sewer is <br /> Installation w, <br /> Residence *r Commercial Other <br /> Number of living units: edrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> - No. Compartments <br /> l <br /> SEPTIC TANK ❑ Type IMfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Line <br /> Distance to nearest: Well Foundation Property <br /> I <br /> Total length/size <br /> LEACHING LINE ElNo. & Length of lines Foundation Property Line <br /> + FILTER BED ❑ Distance to nearest: Well <br /> Number <br /> SEEPAGE PITS ❑ Depth. Size <br /> Foundation Property Line <br /> SUMPS ❑ Distance to nearest: Well - <br /> r' DISPOSAL PONDS O <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> shall not <br /> rules and regulations of the San Joaquin Local Health District. work for <br /> Home owner or licensed agent's signer s torbecomeesu h collo w 9rkmacertify <br /> sr�con'pensation lawst in the oof California." Contractor's lhir hiring or sub-contracting l signature <br /> empty any pe <br /> performance subject <br /> of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> certifies the following:"I certify that in the pe <br /> tion laws of C lifornia." <br /> The app nt must call for all r red inspecti ns. Complete drawl ni reve e side. <br /> Date: <br /> Signed <br /> FORD ARTI TENT USE ONL <br /> F,r Date �, Area O <br /> Application Accepted by ` <br /> � _ Final In do by Date <br /> Pit or Grout Inspection b Da D <br /> 4 ' <br /> Additional Comments: !4J <br /> ❑ Stk 46Cr6781 El 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 Ave., P.O. ^ <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton ., P. Box 2009, Stk., CA 9520 ► it <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. G� <br /> � - � � r� �J ` �•1 <br /> + EH 13-24(REV.I/a 5) INFO `'C(f� 0 ��. ��• <br /> EH W28 ff o 0 <br />