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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT D i all <br />l � p <br />1601 E. HAZELTON AVE., STOCKTON, CA `t <br />Telephohe (209) 466-6781 AUG 2 1 1988 <br />PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br />• {Complete in Triplicate} ENVIROMENTAL HEALTH <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w(FM1T/&MVJCb& application is <br />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 />Local Health District. <br />Job Address City S15 Lot Size PM <br />wxu <br />Owner's Name Address Phone 11,31 <br />q3 <br />AV <br />Contractor Address Q0(i-.LJ'• o. it License N 71(,, Phone _�V <br />I ' wv <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION JV STEM 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 <br />❑ Industrial <br />,,�Oomestic/Private <br />i`i Public <br />I I Irrigation w <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />TYPE OF WELL <br />PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom <br />❑ Manteca �Dia"of-Well <br />Excavation <br />Dia. of Well Casing <br />❑ Gravel Pack <br />❑ Tracy ( <br />Type of -Casing <br />Specifications <br />Cl Other <br />171 Delta c <br />Depth of Grout Seal <br />Type of Grout <br />—.-Approx. Depth, <br />I_I.-Eastern i <br />Surface Seal installed by <br />_ <br />Type of Pump SU H. P.-. ! <br />State Work Done <br />, <br />Well Diameter ' <br />Scaling Material (top 50') <br />B12 <br />Depth <br />Filter Material <br />(Below 50') <br />�— <br />TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION I I DESTRUCTION I ],INo septic system permitted if public sewer is <br />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: <br />Water table depth <br />SEPTIC TANK ❑ Type/Mfg Capacity 3 t No. Compartments <br />PKG. TREATMENT PLT. ❑ Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />FILTER BED <br />❑ No. & Length of lines <br />D. Distance to nearest: <br />Total length/size— <br />Well _.:Foundation Property Line <br />SEEPAGE PITS I ] Depth Size ter+ _ l Number <br />SUMPS ❑ Distance to nearest: Well -Foundation <br />Property Line <br />DISPOSAL PONDS ❑ f.. <br />I hereby certify that I have prepared this application and that the work witl be done in accordance with San Joaquin county ordinances, state laws, and <br />rules and regulations of the San Joaquin Local Health Di§trict. f .# <br />Home owner or licensed agent's signature certifies the following;f <br />"! certify that in the performance of the work for which this permit is issued, I shall not <br />--employ-any win -such manner-asto•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 />The applicant al quired ' i s. Complete.`drawing on reverse side.,,, <br />Signed X Title:Date: <br />r�� <br />DEQ RTMENT USE ON <br />Application Accepted by Date 7 Area r <br />Pit or Grout Inspection by Date Final Inspection by�/`fAis9_ Date <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 />FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEDBY INFO j CASH DATE PERMI7'N0. <br />r,EH 14-241REV. tik51 V(J I r n -;o (f 5 <br />EH 14-2a ( - b 'jet <br />