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PAYMENT«. APPLICATION FOR PERMIT RECEIVED. <br /> s <br /> SAN JOAaUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOGKTON, CA APR 1988 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> { (CDrnp <br /> fete in Triplicate) PERMITJSERVICES <br /> n described. This <br /> San Joaquin Local Health District for a peNo 1862 forcwell//pump and the Runes and t to construt and/or install the work IR Regulations of the San'Joaquin <br /> Application is hereby made to the - <br /> o.549 for sewage or on <br /> made in compliance with San Joaquin County Ordinance N <br /> Local Health District. PM <br /> n City�t-'1 Lot Size <br /> c] d Lover sire <br />`• Job Address PhoneQ <br /> nAddress0 ee <br /> yy�� OI 1 <br /> `7S~1v•�S <br /> Owner's Name STSQ <br /> �"t License No,s 1 r Phone <br /> Address DESTRUCTION ❑ <br /> contractor NEW WELL ❑ WELL REPLACEMENT ❑ <br /> TYPE OF WELLIPUMP: OTHER S4 <br /> SYSTEM REPAIR ❑ PROP LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLO. <br /> SEWER LINES _�--- PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL— <br /> FOUNDATION r� <br /> TYPE OF.WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE Dia. of Well Excavation <br /> ❑ Industrial <br /> C3 open Manteca Open Bottom Specifications <br /> Type of Casing <br /> j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy l Type of Grout �--= <br /> f Cl Delta Depth of Grout Seal <br /> M Public Cl Other F <br /> — <br /> _Apprax. Depth l 1 Eastern H.P. Surface Seal Installed by � f <br /> L 1 1 Irrigation - State Work Done <br /> Repair Work Done ❑ <br /> Type of Pump --�i Seating Material (top 50'1 <br /> Well Destruction ❑ Well Diameter �---- Filler Material l9alow 50'1 <br /> Depth <br /> available within 200 feet"i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ! REPAIRIADDITION LI DESTRUCTION i ! ava(Noilable <br /> septic system permitted if pu is sewer i <br /> Installation wili serve: Residence <br /> Commercial�. Other <br /> Number of living units: Number of bedrooms Water table depth <br /> �tt Character of soil to a depth of 3;.at: Capacity--- No. Compartments <br /> i. SEPTIC TANK ❑ TypelMfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ J, Foundation —�� Property Line <br /> Distance to nearest: Well <br /> Total length!size <br /> LEACHING LINE Cl No.,i Length of lines Property Line <br /> ! FILTER BED <br /> EI to nearest: Well <br /> Foundation <br /> .4 Number <br /> th <br /> I l DepSixe —" <br /> SEEPAGE PITS r Foundation Property Line <br /> SUMPS 0 Distance to nearest: Well <br /> w state laws,DISPOSAL PONDS <br /> thereby certify that L have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, and <br /> El <br /> f s permit is issued, I shall not <br /> rules and regulations of the San Joaquin Local Health following- <br /> that in the hiring <br /> Home owner or licensed agent's <br /> signature certifies the ct Ito workman'srtcoympensation it. aawsaof California." Contractor'ss subwork for which 'o t bworkman`sgompensa <br /> employ any person in such manner as to become sub! f <br /> i <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons 1 <br /> tion laws of California." <br /> The applican st call for all requ' speClions. Complete drawing on reverse side, r_ Q <br /> I Date: lJ <br /> Title: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> I Date Area <br /> I Application Accepted by Date <br /> k. Pit or Grout Inspection by <br /> Date��-- Final lnspect on by <br /> Additional Comments:. ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ❑ Stk 466 6181 Lodi 369-3621 <br /> 1 Applicant flet rn all copes to: Environment I Health Permii►tt/Servi S 1 1.E. Hazelton Ave., .O. Box 2{�9 ��CA�01 <br /> '"" — `.! (��J, PERMIT ND. <br /> r AMOUNT REMITTED K RECEIVED BY DATE <br /> FEE AMOUNT DUE ---y <br /> INFO <br /> •+ EH 13-24(REV.1)n 51 <br /> EH 14.26 -.. - <br />