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- APPLICATION FOR PERMIT <br /> w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL-10N AVE., STOCKTON, CA JUN 5 1987 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rNv1ROMENTAL HEALTH <br /> (Complete in Triplicate) PERMIT/SERVICES application ie <br /> wa a or No. 1f362 for well/pump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Ordinance No.549 for ser agpermit to construct and/or install the work herein descnbed. This <br /> p I G� f�r��J q <br /> made in compliance with San Joaquin Go�ntY CttaLocal Health District. I k j PM <br /> r -�n}O City [�e'�y-^` tot Size t <br /> Job Address ZX0 (•�/ f a'3 ;S1 FI�7� �,' ©a <br /> �� L1 nl� <br /> :53 <br /> Phone <br /> C)V#V`P� Address i'�iJ W r _ <br /> � � ' <br /> *Owner's Name. �+� ���� (�. Phone <br /> s 1111 6 J License No.�---- <br /> �p,�� Address f�1 <br /> 1 E RU <br /> Contractor WELL REPLACEMENT ❑ DESTCTION LD <br /> NEW WELL OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. POOP. LINE <br /> SEWER LINES �— <br /> I t DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> �.� Monriv.q <br /> TYPE OF°WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of ell Casing ' <br /> - INTENDED USE ❑ Manteca Dia. of Well Excavation <br /> ❑ industrial ❑ Open BottomSpecifications <br /> f ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout - <br /> at ❑ DomesticlPrivate ❑ Delta Depth of Grout Seal <br /> ("I public ❑ Other <br /> Surface Seal Installed by <br /> 7 I 1 Irrigation Approx. Depth I I Eastern "State Work Done <br /> a Type of Pump H.P. <br /> Repair Work Done ❑ Sealing Material (top 50'1 <br /> Well Destruction Gl Well Diameter - - <br /> Depth . Filler Material (Below 50'1 <br /> available within 200 feet.) <br /> k i ! TYPE OF SEPTIC WORK:. <br /> ''iiEW INSTALLATION Ia �REPAIRIADDITION (.I DESTRUCTION l 1 lNo septic system ...permitted if public sewer is <br /> Commercial Other�— <br /> lrietaklation'will serve: Residence _ <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Gapacity� No. Compartments <br /> SEPTIC TANK ❑ Type1Mfg Method of Disposal <br /> I <br /> PKG.`.TREATMENT PLT. ❑ <br /> Foundation��-�- Property Line <br /> 4 - 4 a Distance to nearest Well <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Prop" Line <br /> � FILTER BED <br /> L1 Distance to nearest: Well Foundation p rIY <br /> 1 Size I I DepthNumber <br /> ' + ) <br /> SEEPAGE PITS .,, Foundation Property Line <br /> SUMPS L� Distance to nearest: Well <br /> t DISPOSAL PONDS -.':r-❑' - '' `- R <br /> to 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. work for <br /> Home owner or licensed agent's signature certifies th"Golfo workman's man'srtcompensation fify that in the aewsoof California."Contractor's rhir hiring of sub-cont acermit is t nglsignlatuore <br /> employ any person in such manner as to become sub{ rsons subject to workman's compensa <br /> k certifies the following: "I certify that-in the performance of the work for.which this permit is issued, I shall employ pe 1 <br /> r tion laws of California." x 1 -�.+ <br /> l 9 k <br /> l The applicant must ca for all required inspections. Complete drawing on reverse sid �°�11G�� Date: �� ?_-7 9 <br /> `�I PIC �1 Title: !r V•_ <br /> { Signed X Lj + <br /> FO EPARTMENT USE ONLY ] + <br /> Date ! Area '- <br /> Application Accepted by Date <br /> ' Date Final inspection by <br /> I Pit or Grout Inspection by " <br /> Additional Comments: ,r <br /> ❑ Stk 466-6781 ❑ Lodi `369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 <br /> I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH q ' <br /> I INFO .11 <br /> - .--� �y}� <br /> `2 � M <br /> ' . EH13-24(REV.1/H5Y ��- _ s61� / f f <br /> EH 14-28 k ��� <br />