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APPLICATION FOR PERMIT PAYMENT 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> RECEIVED <br /> 1601 E. HAZELTION AVE., STOCKTON, CA SEP 18 1989 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMITISERVICES <br /> rk <br /> . This <br /> maden'compliance with made <br /> San Joaquin County Ordinalnce Nth District for a o.549 for sewageor permit <br /> construct well/pump and the Rues and(Regulations of he Sancation is <br /> Joaquin <br /> Local Health District. <br /> (� n4/�fi> ��}�G,a~ .� �f _ CityT` '` Lot Size PM <br /> Job Address _..�,. <br /> 1 e�� s Phone <br /> Owner's Name Address <br /> Contractor�l..lT_ ,— t31 Address 7 / I ' License Nott`2 Phone <br /> R.,- <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of VVell Casing <br /> Type of Casing Specifications <br /> Domestic/Private El Gravel Pack ❑ Tracy 9 � <br /> 1-1 Public ❑ Other ❑ Delta, Depth of Grout Seal Type of Grout <br /> I I Irfigation .-Approx. Dept�Eastern Surfa e Seal Installed by <br /> H P, State Work Done <br /> Repair Work Done �' Type of Pump - <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 50') _ <br /> 'Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ('I -REPAIR/ADDITION ! I DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.)---. <br /> Installation will serve: -Residence_ Commercial_.— Others <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: �p <br /> SEPTIC TANK 171 Type/Mfg Capacity NorCpmpartments ^` <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 0 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS- I i Depth Size Number <br /> SUMPS Irl Distance to nearest: Well Foundation Property Line <br /> 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 District. <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 of California."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican ust call for all re ed inglections. Complete drawing on reverse side. <br /> Title: — Date: <br /> Signed X <br /> f ' <br /> F EPARTMENT USE 011lLY /��� � <br /> Application Accepted by Date y Area <br /> Pit or Grout Inspection by Date Final Inspection by Datq�� <br /> Additional Comments:,,.4m�: <br /> El Stk 466-6781 ` El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&185 <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 CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ' . 1H 1324IHEV.5irs57 .7JP 75 Z8'3� ZO 41j g�-2337 <br /> EH 1428 <br />