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1 APPLICATION FOR PERMIT 9 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l 1601 E. HAZELTON AVE., STOCKTON, CA PAYM-9N, <br /> Telephone (209) 466-6781 RECEIVED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - (Complete 'ln Triplicate) Abe 10 1990 <br /> un Local Health District for a permit to construct and/or install the work Iherei�ndeNcribed. is application <br /> is <br /> Application is hereby made to the San Joaqor No. 1862 for well/pump and the uin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address <br /> Phone1 f <br /> Owner's Name Address <br /> —_. <br /> 0-1 <br /> Contractor <br /> ` Address,""77-Y i 'Icense No, ` --Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PLJ REPAIR 0L OTHER C3UMP INSTALLATION <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK . _ <br /> PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca bio. of Well Excavation 4 <br /> Type of Casing Specifications <br /> 1111 Domestic/Private D Gravel Pac L1 Tracy Type of Grout -- <br /> I I Public I] Other Cl Delta Depth of Grout Seal <br /> —.-Approx. Depth l I Eastern k,Surface Seal Installed by <br /> I I Irrigation — _ State Work Done \ <br /> Repair Work Done I� Type of Pum H.P.��� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth j I Filler Material Welow 50 <br /> ffi s is <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION I I (No s ptic syavailai f <br /> j Installation will serve: Residence Commercial— Other n �} <br /> k Number of living units: Number of bedrooms <br /> Water tC <br /> abinPih <br /> Character of soil to a depth of 3 feet'c l <br /> SEPTIC TANK Type/Mfg Capacity <br /> ❑ <br /> PKG. TREATMENT PLT. L] Mefhnd,gi-�i~ s7�I <br /> Distance'to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines T <br /> Total length/size <br /> ❑ Distance to nearest- Well Foundation Property Line <br /> FILTER BED I .. <br /> l � <br /> lI Size Number <br /> SEEPAGE PITS I ! Depth Property Line <br /> SUMPS L] Distance oto nearest: Well Foundation ! <br /> r 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 D%i 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, 1 shall not <br /> signature <br /> employ any person in such manner•as id become subject to workman's compensation laws ss California." Contractor's p6osdristring subjecrt to workmansub-contracting <br /> s compensa- <br /> certifies the following: "I certify thai:in-the performance of the work for which this permit is issued,I'shall employ p I <br /> lion laws of California." <br /> The applicant must call f r all required inspections. Complete drawing on re se side. <br /> Signed X ; <br /> Title: Date: <br /> k FO DEPARTMENT USE ONLY <br /> Date v ~ d— a Area <br /> f Application Accepted by <br /> Pit or Grout inspection by <br /> Date Final Inspection b Date <br /> Additional Comments: <br /> d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy B35-6385 <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 CA RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> r +.EH 13-24(REV.i/K51 q o 6— OS <br /> EH 14-2e . <br />