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APPLICATION FOR PERMIT ` , <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT'-,1 <br /> 14�Jo1601 E. HAZE i ON AVE., STOCICTON, CA <br /> Telephone (209) 466-6781 `- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> + 1 �6 <br /> Job,Address `' Gity Lot Size PM <br /> Owners Name;� C � .A SIS. Address Phone 3� pl0 <br /> Con(rac't r Address X1—LJ Bay( ��� J <br /> r r <br /> . License No.3`Z "2VPhon,Z -9-109' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ # ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP- LINE <br /> FOUNDATION = AGRICULTURE WELL OTHER WELL PITS/,SUMPS - c - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA !f CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca it Dia'. of Well Excavation Dia. of Well Casing 'r <br /> ❑ Domestic/Private ❑ Gravel Pack <br /> C1 Tracy Type of Casing Specifications <br /> (-1 Public ❑ Other ll Delta.— Depth,-of-Grout Seal' Type of Grout <br /> ! I Irrigation —.-Approx. Depth l 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 50') '` a <br /> Depth Filler (Below 50') } t- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1'.] REPAIR ADDITION DESTRUCTION I I,INo septic-system permitted if public sewer is <br /> 't ; vailatile flirt 200 feet;), <br /> _._ <br /> Installation will serve: Residence Commercial'1. Othe V <br /> Number of living units: Number drooms � <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - `` CapacityAa q No. Compartments <br /> PKG. TREATMENT PLT- ❑ Method of Disposal <br /> Distance to'nearest: Well Foundation Property Line <br /> li <br /> •ter ! <br /> I <br /> LEACHING LINE No. & Length.of lines 14 fl r Total length/size d K <br /> FILTER BED ❑ Distance to- Barest: Well 50 Foundation—A.Q_,- Property Line e�! <br /> SEEPAGE PITS Depth { Size b`f Number <br /> SUMPS ❑ Distance to nearest: Well .._ Foundation 6 Property Line 5 <br /> DISPOSAL PONDS ❑ I <br /> --I-hereby certify that I have prepared-this application and that the work will-be done in accordance with Sari Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. <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 no <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 /> r; <br /> The applica ust call fo requ' ed inspections. Complete drawing on reverse 'do <br /> Signed X - Title: Date: <br /> FOR DEPARTMENT USE ONLY r �j <br /> Application Accepted by ` + � ✓"+F�� a 1 pate, r "A [ Area <br /> it r Grout inspection by, ate [ Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK e <br /> CASH RECEIVED BY DATE PERMtT'NO. <br /> + EH 13-24 MEV-i i n sl i <br /> EH 14-20 <br />