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r <br /> APPLICATION FOR <br /> SAN JOAQUIN LOCAL HEALTHMDISTRICT RECEIVED <br /> i 1601 E. HAZE.T ON AVE., STOCKTON, CA J U N 2 2 1990 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 1SSUEXNVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMI USERVICES <br /> f 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 /> 4 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> I Local Health District. } <br /> Job Address -`° City Lot Size PM <br /> r ' f <br /> i Owner's Name Address -�~ Phone <br /> C �� � r <br /> Contracio r � CI— Address�w3�l�[7a u'ov � License No. Q_Z PhonE <br /> il� <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 FLO. 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 Well Casing <br /> r <br /> VIlaomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other 1 71 Delta Depth of Grout Seal Type of Grout <br /> l 1 Irrigation __Approx. Depth i I Eastern / Surface Seal Installed by +' <br /> Repair Work Done f ' Type of Pump la__� H.P. Imo — State Work Done VJr <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> !� Depth Filler Material (Below 601 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> �t available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms ` <br /> Character of soil to a depth of 3 feet: Water table depth ' <br /> SEPTIC TANK .a ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT..C3 Tom,- ,:--_�'— �- -- —< � Method of Disposal <br /> r Distance to nearest: Well Foundation Property Line`'_- <br /> LEACHING <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distanceto_nearest: Well Foundation Property Line � <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS 0 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 arid,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." Contractor's 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 /> r The applicant must c r alk required inspections. Complete drawing on reverse side. 4 <br /> Signed X_ iQ�S—� Title: a4 Date: <br /> F R EPARTMENT USE ONLY <br /> ' s V `J <br /> Application Accepted by Date Area <br /> I Pit or Grout Inspection by Date Final Inspection by Date 7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED ,qSH J RECEIVED BY `gyp DATE "PERMIT'NO.+.EH13-24(REV.1/mb) `��EH 14-26 <br />