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i <br /> I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E."HAZEL T ON AVE., STOCKTON, ,® <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR <br /> FROM DATE ISsa.UPD <br /> (Complete in Triplicate) w �, ! 1988 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> APp y p <br /> made in compliance with San Joaquin C <br /> ounty Ordinance No. 5491or sewage or No. 1862 for well! u p a��dh ,flulesnd Rerg" tons of the San Joaquin <br /> Local Health District. <br /> �QQ �, Gi4r City Size PM <br /> Job Address 1 <br /> Address hone 4 7 <br /> Own is NameG <br /> a I liA� . Q F J.. <br /> SAddress License No. <br /> z� Phon <br /> Contfacto <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑l / DESTRUCTION ElL9 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR • 1 OTHER i] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA —CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ industrial t <br /> i ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specificatians� <br /> lCl Other F1Delta Depth of Grout Seal Type of Grout <br /> { I Public <br /> I I Irrigation —..Approx. Depth �t I Ea�Tern Sue Seal Installed by <br /> L***"Type of Pum _.fJ� H. State Work Done <br /> 1 Repair Work Donep <br /> Well Destruction ❑ Well Diameter Sealing:Material ltop 501 <br />(rDeptti Filler Material (Below 501 w <br /> 1 , 'TYPE OF SEPTIC WORK- NEW INSTALLATION I.I REPAIR/ADDITION 13 DESTRUCTION t I (No septic system permitted if public sewer is <br /> f <br /> --available feet--)-, <br /> feet-1 -tom <br /> Installation will serve: Residence Commercial Other <br /> Number of living units:. Number of bedrooms <br /> Character of soil ta'a depth of 3 feet: z Water table depth r <br /> iE Capaci[ No. Compartments <br /> SEPTIC TANK ElType/Mfg y + <br /> PKG. TREATMENT PLT. ❑ I I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 1 Total Length/size <br /> I <br /> FILTER BED ❑ Distance to nearest: Well 1 Foundation Property Line <br /> s <br /> SEEPAGE PITS f! Depth Size t Number - <br /> SUMPS ❑ Distance to nearest: well. \Foundation Property Line <br /> DISPOSAL PONDS ❑ I i . <br /> hereby certify that I have prepared this application and that the�r'k 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. <br /> Home owner or license signature certifies the fall ng: "1 certify-that in the performance of the work far which this permit is issued, I shall not <br /> employ any person 3.such man er as to beco a subje orkman's sation taws of California." Contractor's hiring or sub-contracting signature <br /> ' certifies the follo : "1 certify t int the wor r'which this per t is issued, I shall employ persons subject to workman's campensa <br /> i <br /> tion laws of Ca <br /> The applican or requ Compl a draw-w ing on rev <br /> Signed X Title: <br /> Q Date: <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> C V tJ <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by `Date Final Inspection by Date <br /> k Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . <br /> ffZ;NETDUEE ��AMOUNTCK RECEIVED BY DATE PERMI7'N0. <br /> REMITTED CASH <br /> EH 13-24 IAEV. <br /> EK 14.28 <br />