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q <br /> 0 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZE`T ON AVE., STOCKTON, CA PAYMENT <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) jUL 27 1988 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. pplication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump anr�V1� JAki( San Joaquin <br /> Local Health District. PERMIT I SERVICES <br /> Job Address <br /> <f S. el- Ve 577 City Lot Size �v f PM <br /> Owner's Name V45 ^"° Address 2&Z Y P9, Phone %`l —3`l`� <br /> Contractor 5P€c_'�'/24° Addresses . TL 5 icense No. Phone /3f <br /> TYPE OF WELL/PUMP: NEW WELL 113' WELL REPLACEMENT 11 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E <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 ❑ Oen Bottom ❑ Manteca Dia. of Well Excavation JV40 Dia. of Well Casing <br /> ❑ Domestic/Private 9_ ack ❑ Tracy- Type of Casing P144- Specifications <br /> 1`1 Public '° ❑ Other n Delta Depth of Grout Seal 4Z .3 0 ® Type of Grout&& <br /> IM' T�2t Approx.,Depth I I Eastern Surface Seal Installed by -5&c77ZU,4i _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WOR NEW INSTALLATION I 1 EPAIR/ADDITION l l ESTRUCTION 1 1 INo eptic system permi d if public sewer is <br /> availa within 200 feet.) <br /> ns4allation will serve: Res encs Commercial_ Other <br /> N ber of living units: Number of bedrooms <br /> Char ter of soil to a depth of 3 f t: WX <br /> SEPT T K ❑ Type/Mfg Capacity N <br /> PKG. TREAT NT PLT.❑ MDistance to near t: Well Foun ion Prop V <br /> L ACHING LINE ❑ No. & Length of lines Total length/size <br /> FIL R BED D <br /> Distance to nearest: Foundation_ _ Property Line_ O <br /> SEEPAG ITS 11 De h Size Num r10 <br /> "SUMPS ❑ Dista to nearest: Well Foundation perty Line <br /> DISPOSAL PO S ❑ <br /> 1 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 Sari 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." $trE &1410K X <br /> The applicant pust call for all required/iIispections. Complete drawing on reverse side. J°��®� <br /> Signed " Title:. R Date: <br /> R.DEPARTMENT USE ONLY <br /> Application Accepted by, p Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C1eca 823-7104 ❑ Tracy 835-6385 a <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk, CA 9 01 <br /> FEE'' AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT*NO. <br /> INFO <br /> +.EN13.24(REV.1 i e 5) _ <br /> EH 14-26 , i <br />