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I <br /> ` `0.. APPLICATION FOR PERMIT PAYMENT <br /> a <br /> SAN JOAQUIN LOCAL HEALTH F — "'� RECEIVM <br /> 1601 E. HAZEL T ON AVE., STOCK- 17 11189 <br /> Telephone (209) 466-6781 C� <br /> PERMIT EXPIRES 1 YEAR FROM D. / MENTAL HEALTH <br /> (Complete in Triplicate) ll UTISERVICES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe 1. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for 3 of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> FAIROAKS RD. City TRAMLot Size PM <br /> Owner's Name W. D. O. INC . Address P . O. B O X 134 Phone 835-7284 <br /> Contractor_H F N N F AJ G S R R O S _ Address��5 2 A F l A N fl A I F UE F _License Nv.2 f1$ Phone545- 1185 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERU TEST HOLE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE #2 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X] Domestic/Private ❑ Gravel Pack X7 Tracy Type of Casing Specifications <br /> ❑ Public COMTUnity C] Other 71 Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation well _..Approx. Depth I I Eastern Surface Seal Installed by <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 WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other 0 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 San Joaquin Local Health Diltrict. <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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Co le r ing on rgverse side. p <br /> Signed X Itle� �. Date: �— I3 Td <br /> ORD ARTMENT USE ONLY <br /> Application Accepted by Q Date / Area w.+ <br /> Pit or Grout Inspection by Date �V/l Final Inspection by Date <br /> Additionai Comments: <br /> ❑ Stk 466-6781 C1 Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED C �RE�CE{IIVVEDD�BY Liz) <br /> P`ERMITNO. <br /> + EH 14 2B[RN.r i n 51 ��] CS �/�. � i I <br />