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APPLICATION FOR PERMIT m <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON SAVE. <br /> Tele STOCK`�ON, CA <br /> PERMIT phone f2pg) 466-6781 <br /> EXPIRES ? YEAR FROM <br /> APPiication is hereb (Com M DATE ISS <br /> Y made to the r i. r t 4'• plete'in ISSUED' <br /> made in compliance with San Joaquin San Joaquin Local Health District fora " Plicate) F <br /> Local Health District qurn Coun <br /> r. "r ry Ordinance 548 for Permit to <br /> #, No, construct and/or install the work <br /> sewage or No. 1g�for well/pum herein described. <br /> Job Address "' `"`' Y y '• vim. P and the R This <br /> - Ryles and Re application is <br /> I� gulations of the San Joaquin <br /> Owner's N I� 3 . H s .,. L . <br /> ame I` t City <br /> �lf s �� r.i t;" Lot Size <br /> Contr Address PM <br /> racto <br /> 9 <br /> TYPE OF WELL/PUMP: Address70 T Phone <br /> NEW" <br /> I� WELL ❑ License No. <br /> DISTANCEPUMP INSTALLATION ❑ WELL REPLACEMENT ❑ Odd <br /> TO NEAREST: SEPTIC TANK DESTRUCTIONPhone <br /> SYSTEM REPAIR ❑ <br /> FOUNDATION SEWER LiNES OTHER <br /> INTENDED USE `AGRICULTURE WELL DISPOSAL FLD.� PROP. <br /> ❑ Industrial TYPE OF WELL OTHER LiNE <br /> "•pROBLI All A CONSTRUCTION WELL PITS/SUMPS <br /> ❑ Domestic/private <br /> _' <br /> Op in $OttOm ❑ MantecaDia. SPECIFICATIONS <br /> ❑ Public ❑ Gravel pack - of Well Excavation <br /> ❑ Other ❑ Tracy <br /> Type of Casing <br /> ❑ Irrigation 1l Delta th of Grout Dia• of Well Casing <br /> ❑ <br /> Repair Work Done �AI?prox. Depth t ❑ East ern DepSeal Specifications <br /> ❑ Type of pump Surface Seal Installed by Type of Grout <br /> Well Destruction ❑ I� �� H.P. <br /> ' <br /> Weil Diameter ---------- State Work Done <br /> Depth �i Sealing Material (top 50'I <br /> TYPE OF SEPTIC WORK; NEW IfVSTALIATION Filter Material (Below 50') <br /> ❑ REPAIR/ADDITION ❑ . <br /> Installation will serve: DESTRUCTION [2 Residencel_ (No septic system <br /> Commercial available within 200 feet tited if public sewer is <br /> Number Of living units: --` Other <br /> Number of bedrooms �— <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK <br /> Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ <br /> Capacity No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> 11: — Foundation�� Pro <br /> LEACHING LINE Percy Line� <br /> ❑ No. & Length of lines <br /> - <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> SEEPAGE PITS Property Line <br /> ❑ ' Depth -1� . <br /> SUMPS Size <br /> ❑ Distancl to nearest: Well�tiNumber <br /> DISPOSAL PONDS Foundation <br /> Property Line <br /> 1 hereby certify that I have prepared 11I'6. application and that the work will be done in accordance with San Joa uin <br /> rules and regulations of the San Joaquin Local Health District, � <br /> Home owner or licensed agent's signature certifies the following: 4 county ordinances, state laws, and <br /> employ any perm in such manner as to become subject to workman's compensation in hlaws of California-"Contractor's hiring o► <br /> certifies the following; "l certify that in the Performance of the work for which this ermites issued, �alOf hem work for which"this permit is issued, f shall not <br /> tion laws of California." g sub-contracting signature <br /> P p Y Persons subject to workman's compensa- <br /> The applicant at call for.all re ire linspections. Complete drawing on reverse side. <br /># Signed t� "I <br /> Title: <br /> Date: — r <br /> FOR DE ARTMENT USE ONLY l <br /> 'Application Accepted by 4— <br /> Grout Inspection by Date Area <br /> "f �a� Date <br /> Final inspection by <br /> m <br /> a! Comments; Date <br /> 466-6781 Lodi 369-3621 <br /> t 't- Return �w ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> cop to: Environmental Health Permit/Services 1601 E. Hazeltori Ave., P.O. Bax 20081"Stk., CA 95201 <br /> 4 FEE DUE <br /> AMOUNT <br /> ' INFO IAMOUNT REMITTED ° <br /> 4 r 6 CASH RECEIVED BY <br /> DATE <br /> f II q PERMIT'NO. <br /> >w\,r, <br />