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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br />'E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0,1 2 ;J 1989 . <br /> r (Complete in Triplicate) <br /> i 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 /> i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for weil/pump and the Riilas`and Aegulatibris of the San Joaquin <br /> L r local Health District. <br /> V Cjty S Lot Size PM <br /> Job Address 1 + <br /> 04V hi f y fJ <br /> ;2 330 <br /> Owner's NamePhoney, r� ��- � _- Address <br /> I Iicense No. Phon 813/ <br /> Contractor +� Address <br /> TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR J$ 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 Well Casing <br /> 'Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel <br /> [1 Public F1 Other 'I F1 Delta Depth of Grout Seal Type of Grout — <br /> 47%irrigation Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pulmp h'-' aLk-­ H.P.—1' Z - State Work Done R <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth °1 Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION f I DESTRUCTION 1 1 iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> r Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/.Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> { <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:'- Well Foundation Property Line <br /> 1 <br /> C SEEPAGE PITS l 1 Depth Size _ Number <br /> i <br /> SUMPS LlDistance to nearest: Well Foundation Property tine <br /> .DISPOSAL PONDS ❑ � � r `�'--���'� -�: . � .—�.. <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 /> k rules and regulations of the San Joaquin Local Health District. <br /> ify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert <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." i F <br /> Theapplicant ust call r all required inspections. Complete drawing on reverse side. �Q� <br /> Signed X <br /> I Title Date: � ,90- <br /> r - , <br /> DEPARTMENT USE O Y <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection b Datta��aid <br /> t Additional Comments: t <br /> F] Stk 466-6781 ❑ Lodi 369 3621 L3 Manteca 823 7104 El 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 /> FEE AMOUNT pUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH13-24(REV.r/„5) - <br /> EH 14-29 1 <br />