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APPLICATION FOR PERMIT <br /> SAN. �•.. ,�. <br /> JOAQUiN LOCAL"HEALTH DISTRICT <br /> j <br /> 1601 Ln HAZEL r ON AVE., ' r <br /> f Telephone (209) 4 6-67$,TON, CA <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> A ' s . (Complete in Triplicate} <br /> Application is hereby made to the San Joaquin LocalHealthDistrict for a permit to construct ' <br /> made in compliance with San Joaquin County <br /> Local Health District, tY Ordinance No,549 for sewage or No, 1862 for well/pump and the Rgles and Re ul ` <br /> uct and/or install the work herein described. This application is <br /> g aeons of the San Joaquin <br /> Job Address „ • 6 <br /> :bE i <br /> .. l <br /> t ' City Lot Size i <br /> Owner's Name =. r C�.—P PM <br /> � Address - — = <br /> Contractor Phone <br /> TYPE pF , <br /> '• "'. .,M Address <br /> WELL/PUMP" <br /> NEW; EJ INSTALLATION (Z DESTRUCTION [ILicense No. _ <br /> WELL REPLACEMENT Phone r <br /> ( <br /> DISTANCE TO NEAREST: SEPTIC TANK too SYSTEM REPAIR ❑ <br /> * 1���`--•�:EW_Ef�,�.li�E5 OTHER ❑ <br /> FOUNDATION` - DISPOSAL FLO. <br /> - � AGRICULTURE W4LL PROP•'LINE 'i5 L-I <br /> INTENDED USE TYPE OF WELD ra, : -11 fi I OTHER WELL PITS/SUMPS fi <br /> Q Industrial _ PROBLEM AREA MPS SPECIFICATIONS <br /> Open Sottom• ❑ Manteca <br /> Domestic/Private ❑_Grave! Pack Dia• °fdd Weli•Excavation / r, ,. <br /> ❑ Public ❑ Tracy Type df Casing=`Sip 1 Dia. of Well Casing �5 <br /> ❑ Other [J-Delta f l t t Specifications <br /> ❑ Irrigation (�Depth2oflGrout SeapW ` <br /> p ❑ 3 Typeof <br /> m• Depth Eastern3 r Su4, Seal Installed by Type of Grout <br /> Repair Work Done (� <br /> Well Destruction p —�"-S _ H•P`� I <br /> ❑ Well Diameter r State Work Done f rti y <br /> Sealing Material (top_ <br /> riaw 50') <br /> 50�j1 ` <br /> Depth Filler Matel (Belo <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septi <br /> Coc system <br /> f _ <br /> Installation will serve: Residence available within rn eeremtilYed if public ewer is` <br /> Number of:livin'g units:mmercial Other E <br /> Number•of bedrooms Character. - <br /> of soil.to a depth of 3 feet: <br /> SEPTIC TAN­IC _ ' <br /> ❑ Type/Mfg Water table depth� <br /> ttPKG:,.TAEATMEN%LPLTr-❑ Capacity <br /> Compartments <br /> Distance to nearest: Well <br /> Foundation Ii+l <br /> ` ' eti5od-of'Disposal` r'it"ffitl;e�`�� <br /> --� _ property Line�� - <br /> -.LEACHING-LINE ❑ No. & Length of lines flew ' <br /> FILTER SED ❑ Distance to nearest: '—Total length/size <br /> Well Foundation <br /> I SEEPAGE PiTS Depth Property Line <br /> SUMPS Size <br /> D Distance to nearest: WeII Number i <br /> DISPOSAL PONDS ❑ — Foundation <br /> Property Line <br /> i hereby certify that! have prepared this application and that the work will be done in accordance with San Joaquin county ordinances <br /> rules and regulations of the San Joaquin Local Health district. <br /> ,Home owner or licensed agent's signature certifies the following. , state laws, and <br /> C+employ any person in such manner as to become subject to wo kman`s c'mpensat on laws of California."Contractor, hiri <br /> performance of the worki-for whicwthis per-mit wissued, I sh it not <br /> kVcen the <br /> rtifies the following: "i certify that in the Performance of the work for which this permit is issued, i shall employ'pers°ns subject;to workman's c <br /> motion laws of California," ng or sub contracting signature <br />_The applicant rest call for all required inspections. omplete drawing on reverse side. f °mpensa- <br /> L+? I �G/ / 0 Cv€ <br /> 3Signed �+Gc. �rA� <br /> _ Title%t O W <br /> � <br /> :ti,-.0wAccenterf <br /> Date:FOR"DEPARTINEIYT-USEn y <br /> i Date Z3 S <br /> t or nspection b _ Area <br /> Y Date l t. <br /> ; <br /> Final inspection by iy1�tionai Com ie s: 101 1' ! � <br /> G� Date <br /> +0 <br /> k <br /> 466-6781' Lodi 369-3621 ❑ Manteca 623-.7104 <br /> Int- Return all copies to: Environmental ❑ Tracy <br /> Health Permit/Services 1601 E. Hazelton A e. P.O. Box 2009, Stk., CA 95201 <br /> FEE A <br /> DUE MOUNT AMOUNT c i <br /> INFp- _ _ <br /> �� y C —RECEIVED BY _DATE ,. _ <br />