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APPLICATION FOR PERMIT k <br /> SAN JOAO.UIN LOCAL N$LTHISTRICT CA <br /> 1601-E. <br /> Hq_ELTON AVE.,. <br /> Telephone (209) 466-6781 ; SEP 2 5 1987 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,: ;�` <br /> (Complete in,TripliC8te) n is <br /> rmit to construct and/or install the w ,E"RQ+A�o6I�AWWEA Joaquin <br /> rr <br /> Application is hereby made to the San Joaquin Local Health District for a peRules <br /> 7 1 <br /> m <br /> ode in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Ru es a <br /> Local Health District. -.,F _ ! r, Lot-Size PM <br /> Cr fj�ii�r'Q�� City <br /> Job Address p Phone ` <br /> l ` `k Address -1 <br /> Owner's Name " o+-_Phone <br /> _ add S, License No`� <br /> WL�� Address J DESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT ❑ <br /> NEW WELL OTHR ❑ ,! <br /> pE OF WELL/PUMP: SYSTEM REPAIR ❑ t.�,, 1 PROP UNE <br /> PUMP INSTALLATION ❑f DISPOSAL FLD. <br /> SEWER LINES PITS/SUMPS �— C <br /> AGRICULTURE WELL OTHER WELL <br /> DISTANCE TO NEAREST`. SEPTIC TANK <br /> FOUNDATION. <br /> PROBL CONSTRUCTION SPECIFICATI pia. of Well Casing <br /> INTENDED USE TYPE OF WELL Dia_ of Well Exc ! <br /> c3 Open Bottom Q Manteca ava Specifications r <br /> ❑ l dustrial 1 racy Type of Casing <br /> Tyle of Grout <br /> -�aavel Pack Depth of Grout Seal <br /> TTT-omesticlPrivate} ! Data .� r <br /> ❑ Public ❑ Ot�er Surface Seal Installed by ' <br /> I M�pprox. Depth D.Easter;- State Work Done <br /> ❑ irrigation H,p? <br /> Repair Work Done' ❑ Type of'Pump -- <br /> '"Sealing Material atop 50'1 <br /> Well Destruction ❑ `Well Diameter Filler Material (Below 50') <br /> E Depth perm <br /> if public sewer is <br /> REPAIRIADDITION ❑ DESTRUCTION ❑ aNailabpe1withm 200 fee�t.I <br /> TY OF SEPTIC WORK: NEW INSTALLATION ❑ (� <br /> f - Other <br /> esidence -Commercial <br /> Installation will se - <br /> r of bedrooms Water table depth <br /> Number of living units: r,%t <br /> No. Compartments C Character of soil to a depth of 3 feet: Oapacity� n <br /> osal <br /> SEPTIC TANK C1Type/Mfg Method of Disp <br /> I <br /> PKC. TREATMENT PLT. Cl Property Line�� 1 <br /> Distance to nearest: Well Founda <br /> Total th/size <br /> LEACHING LINE Q No. & Length of lines Foundation prop Line(— <br /> l FILTER BED ❑ Distance to nearest: Well <br /> ��� <br /> Number s <br /> ❑ Depth Size Property Line <br /> SEEPAGE PITS Foundation <br /> SUMPS ❑ 'Distance to neared_Well r .� <br /> L - a and <br /> —brisPOSAL"PONDS ❑ - <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state I shall not <br /> rules and regulations of the-San Joaquin Local Health District. I certify that in the performance of the work for which this permit is issued, <br /> Home owner yr licensed agent's signature certifies the following: ' nation laws of California." Contractor's ngisubject to workmaub-contractng or sn's compensa <br /> employ any person in such manner as to become subject to workman's comps <br /> certifies the following:'"1 certify that in the performance of the work for which this permit is issued,l shall employ,p <br /> tion laws of California." I lete drawing on rev e side. <br /> The applicant all f r all ad inspections. Camp Date: <br /> Title: <br /> Signed <br /> FO DEPART ENT USE ONLY � � <br /> Area <br /> Date T . <br /> Application Accepted by -r_ -- Date <br /> Date Final Inspection b G rcw�C/ <br /> Pit or Grout Inspection by -f--c77 y <br /> / v 836-6M /00 ,�G! <br /> Additional Comments: ❑ Tracyi�Sr <br /> ❑ Stk t- Re 81 <br /> ❑ Ladi 369 3621 Q Manteca 623 7 CA 95201 c <br /> Applicant- Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., �,. B✓ <br /> CKDATE PER0i'TNO:' . <br /> CASH RECEIVED BY <br /> h FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> +EH 13-24(REV. /135) D (!0 <br /> EH 14-25 <br />