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{ <br /> r <br /> APPLICATION'`FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LT CKTON <br /> 1601 E. HAZE IT ON AVE., S 0 , CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ` Job Address City �6 C Lot Size S�"PM <br /> Owner's Name Address .. -' �' Phon ,67 <br /> Contractor Address . 1iicense No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLA MENT C] 'DESTRUCTION ❑ <br /> PUMP INSTALLATION SYST REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION A RICULTU WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A EA CONSTRUCTION SPECIFICATIONS "" a <br /> w(r <br /> ❑ Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy- Type of Casing Specifications <br /> r 4"1 Public C1 Other ❑ Delta -.. -�. pth of Grout Seal Type of Grout ._. <br /> I Irrigation -Approx. Depth'-I 1 Easter Su ce Seal Installed by - 1 <br /> Repair Work Done ❑ Type of Pump H.P. State Work D�e <br /> Weil Destruction ❑ Well Diameter Sealing Material fto�5011 f <br /> Depth Filler Material (Below 50'1 C/11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITION L1 DESTRUCTI No sep is system permitted if public sewer is <br /> vara within 20D leet.) <br /> installation will serve: ..Reside rt ommercial_ Other <br /> Number of living units: • Number of bedroom_s I <br /> Character of soil to a depth of 3-feet: er table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity ! fVo. Compartments <br /> PKG. TREATMENT PLT. ❑ "x y Method of Disposal <br /> rDistance to.nearest: Well --­-Foundation Property Line F <br /> a,R�T - <br /> LEACHING LINE ❑ -No. & Length of lines Total len gth/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS D 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 District. 1 <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 require inspections. mplete drawing on reverse side. 1 . <br /> Signed X Title: Q"7\42/XZ�_ Date: <br /> .,��/��� R DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by Dat ./ Area <br /> Q . � <br /> Pit or Grout Inspection by a e Final Inspection byS�lr6✓'LZL — Date 1r) <br /> I Additional Comments: & tLG v CLC Z <br /> ❑ Stk 466-6781 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT'NO. <br /> INFO _ <br /> r_. <br /> + EH13-24IREV.r/xsl ( � _ �"���� <br /> EH 14-26 <br />