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APPLICATION FOR PERMIT PAYMENT <br /> SAN JOAQUIN LOL HEALTH DISTRICT RECEIVED <br /> - 1601 E. HAZELTON AVE., STOCKTON, CA 9 1987 <br /> Telephone (209) 466-6781 T <br /> pI <br /> PERMIT EXPIRES 1 YEAR'FROM DATE IS ENVIRONMENTAL HEALTH � <br /> (Complete in Triplicate) Ps111�6Te�$ , � �y <br /> } cation is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein cr <br /> made a compliance with S Joaquin County Ordinance No.549 or sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. M <br />` Lf[{7 �Il p� w City <br /> Job Address I— �� JS• <br /> /L�C 7� /✓ T Phone <br /> P „ <br /> �...;-:--;:.� Address <br /> Owner's Name Z���� <br /> P 1oQ�+� /��,,,,?� � License No.��—Zf Phone <br /> Contractor Address_ <br /> I WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ _ - <br /> PUMP INSTALLATION ❑— <br /> =- SYSTEM-REPAIR 0�-~-- '*— Y_' OTHER_�F— N <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION'— <br /> TYPE <br /> OUNDATION'�— AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. <br /> ❑ Industrial Type of Casing Specifications <br /> ❑ Domestic/Private E3 Gravel Pack El Tracy Type of Grout <br /> ❑ Other El Delta Depth of Grout Seal <br /> ❑.Public <br /> rn Surface Seal Installed by <br /> Irrigation _�PProx. Depth 1: Easte <br /> Ela, H P. State Work Done <br /> Repair Work Done ❑ Type of Pump Sealing Material Stop 50`) <br /> Well Destruction F1 Well Diameter Filler Material (Below 50') <br /> } Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION ❑ DESTRUCTION ❑ availablelw thin 20O feet.) if public sewer is <br /> Installation will serve: Residence— Commercial--Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> r <br /> 1Total length/size <br /> i LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED . <br /> ED Distance to nearest: Well Foundation P rt1/ <br /> Size. ,NumbeJ_.�.�. �--� --- -----,�;.�--,-:._;:�-�.,•----. <br /> SEEPAGE�PITS rte, -� papth, _ Property Line <br /> r <br /> SUMPS ❑ Distance to nearest: Well Foundation P rty <br /> DISPOSAL PONDS ❑ <br /> f will be done in accordance with San Joaquin county ordinances, state laws, an <br /> I hereby certify that I have prepared this application and that the work <br /> rules and regulations of the San Joaquin Local Health District. <br /> g work for <br /> Home owner or lice rlssuch manner tobecomesubjects to workman'srtcompensation laws ify that in the oof California." Contractor's hiring or sub-contracting signature <br /> l <br /> employ any person arsons sub act to workman's campensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ p ] <br /> tion laws of California."- <br /> E The applicant st c for all requir inspections, Complete drawing onYevarse side. Z0 <br /> Title: <br /> ! _ Date: <br /> r' "''�'-�"� <br /> j ` Signed)C f . <br /> it FOR DEPARTMENT USE ONLY U� <br /> 11 Date _ # <br /> Application Accepted by / � <br /> r 5 Final inspection by <br /> Pit or Grout lnspectio y ; <br /> Date�� <br /> Additional Comments: v <br /> [IStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant Return all copies to: Environmental Health permitl5ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F RECEIVED BY DATE PERMIT`NO. -- <br /> FEE AMOUNT REMITTED <br /> INFO y AMOUNT DUE CASH <br /> '+EH 13-24(RFV.1/851 _ T <br /> EH 14-26 <br /> tav - •- ._.... _... .. ... <br />