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APPLICATION FOR PERMIT - SRN JOAaUIN LOCAL HEICT ALTH 1601 E. HAZE.i ON AVE., Telephone (209) 466-6781 I YEAR FROM DATE ISSUED PERMIT EXPIRES lete i Triplicate) (GOmp � ((cation is and the Rules and Regulations of the San Joaquin uin Local Health District for a permit to construct andlor install the work herein described. This app Application is hereby made to the San CouQty Ordinance No.549 for sewage or NO. 1862 for welllpump made in compliance with San Joaquint PM Local Health District, CJC�71? Lot Size PO4AL r city -O� • a Job Address r�j Phone Z f •Address G EL, f j �'* G r Is Z �7 —GF�Phon& �n.lrgA h 1� Owner's Name aharnd �. License o• ! r Address Z `�F s DESTRUCTION ❑ yy dG ❑ .n I� NT I s f$ Contractor �j'S — WELL flEPLACEME � Sir !' S NEW WELL ❑ OTHER TYPE OF WELLIPUMP: ` SYSTEM REPAIR ❑ U PROP. LINE r PUMP INSTALLATION ❑ DISPOSAL FLD— PITS/SUMPS '. SEWER LINES �4�•a DISTANCE TO NEAREST: SEPTIC TANKS--- AGRICULTURE WELL �' OTHER WELL FOUNDATION _�— k pROol, EM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing 1 INTENDED USE TYPE OF WELL pia. of Well Excavation Specifications ❑ Open Bottom"y^C ❑ Manteca ❑ industrial � ❑ Tracy Type of Casing I Type of Grout �'�''t&" ❑ Domestic!Private ❑ Gravel pack pepth of Grout Seal 7 �— T1 Delta ; ("1 Public fir Other A `; Surface Seal Installed by �.ApP'.rox. Depth. I I Eastern Y State Work Done l 1 irrigation H.I?. Repair Work Done ❑ Type of Pump Sealing Material [top 501 Well Destruction ❑ Well Diameter --, t Filler Material (Below 501 V 1 Depth available within 200 feet.) ! SEPTIC WORK: NEW INSTALLATION l-i REPAlR1ADDITION L I REST11.11111RUCTION I 1 1No septic system permitted if public sewer i [t rr TYPE OF SE NO )� Commercial Other��-- J\L/ V stallation will serve: Residence Number of bedrooms Water table depth Number of living units: i Character of soil to a depth of 3 feet: capacity— No. Compartments SEPTIC TANK. El. Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Foundation_ —Property.Ume�---- [ Distance to nearest: Well Total length/size F LEACHING LINE ❑ No. & Length of lines Foundation Property Line !�i['FILTER BED ❑ Distance to nearest: Well _ Size Number SEEPAGE PITS I i Depth Pro rt Line ' Ll Distance to nearest: Well Foundation y^ SUMPS i r f DISP05AL PONDS ❑ I hereby certify at the work will be done an accordance with San Joaquin county-ordinances, that I have prepared this application and th state laws, and rules and regulations of the San Joaquin Local Health District. work for Home owner Or licensel not d agent's signaturebecome subject thethe wing: " n'srtcompensation lify that in the aws Of California."performance Contractor's!hir ng or su4 corlt act ngthis permit is issued, lsignlaturre employ any.parson n such manner asR arsons subject to workman's compensa- 9certify that iri the performanep of�the work for which this permit is issued,l shall employ p 1 , certifies the following: ' p tion laws of California." "' i t l The applicant must call for all required inspections. Complete drawing on reverse side. [ Z `/ qA[ C.• �GOl :�cr(//4�✓Date: may._) Title: Signed X FO PA T T USE ONLY �] ZZ- r � 7 k Date j Application Accepted by bate Final Inspection b Date r Pit or Grout Inspection by —�� Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 [3Stk 466-6781 11 Lodi 369-3621 Applicant - Return all Copies to: Environmental Health Permit/Services. 1601 E. Hazelton Ave., P.O. Box 2003, Stk., CA 9520 CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH. INFO } ♦.EH 13-24IREV.1/951 EH 1428 w ` l