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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1641 E. HTelephane 09)ZELTI ON X466-678iTON. CA , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t <br /> tCompiete in Triplicate) This application is <br /> 4 and the Rules and Regulations•of the San.loaqum <br /> to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. <br /> Application is hereby made Ordinance No.w <br /> for sewage or No. 1862 for Weill pomp <br /> made in compliance with San Joaquin County S 5�} !,` PM <br /> Local Health District. w Old Lot Size <br /> �-� City <br /> Jab Address� _ -� <br /> Phone <br /> `ddress <br /> Owner's Name Phone <br /> License No._�— <br /> I <br /> Address - �'— DESTRUCTION ❑ <br /> Contractor NEW WELL ❑ WELL REPLACEMENT ❑ OTHER ❑ <br /> TYPE OF WELL/ ' SYSTEM REPAIR ❑ PROP, LINE <br /> PUMP INSTALLATION ❑ SEWER LINES fes— DISPOSAL FLD• PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK __— AGRICULTURE WELL OTHER WELL� <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL. <br /> " .pfOBL CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> -4 1 ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Open Bottom Type of Casing <br /> j ❑ Industrial rp.RTracy Type of Grout <br /> i ❑ Domestic Iprivate ❑ Gravel Pack t Depth of Grout Seal <br /> L] other ❑ Delta <br /> ❑ Public Surface Seal Installed by <br /> --Approx. Depth ❑ Eastern State Work Done <br /> ❑ Irrigation <br /> Type <br /> Repair Work Done 171YP of Pump Sealing Material atop 50"! <br /> Well Destruction ❑ Well Diameter —Depth Filler Material (Below 50'1 <br /> REPAIRIADDlT10N ❑ DESTRUCTION 'aNailablelwt in 200 feet-) <br /> tted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ a <br /> Installation will serve: Residence— <br /> Commercial `Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity_ No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal. <br /> ! PKG. TREATMENT PLT.❑ r Foundation -` Property Line <br /> ' Distance to nearest: Well <br /> t Total length/size <br /> i LEACHING LINE ❑I.. No. & Length of lines Well Foundation property Line <br /> - aFILTER BED [3 Distance to inearest:� <br /> a : <br /> -y t. <br /> k ❑ Depth Size <br /> Number <br /> SEEPAGE PITS Foundation Property Line <br /> SUMPS ❑ Distance to nearest: Well <br /> ounty odir <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application an that <br /> work will be done in accordance with San Jo4ur Iwstate laws, and <br /> hrch this permit iounty s ordinances, <br /> ed, I shall not <br /> rules and regulations of the San Joaquin Local Health I certify that in the performance of the work <br /> ring or-sub-contracting signature <br /> Home owner or licensed agent's signature certifies bj following: " nsation laws of California."lemploContry <br /> olsubj cc t workman's compensa- <br /> ( employ any person in such manner as to become subject to workman's comps <br /> certifies the following: '9 certify that in the performance of the work forwhich this per <br /> is issued,i shall employ persons <br /> tion laws of California." <br /> ins c' ns. Complete drawing on reverse side• <br /> The app lira st call for I r Pe Date: <br /> Title: <br /> Signed <br /> �. FOR DEPARTMENT USE ONLY <br /> Date Area <br /> C`� <br /> Application Accepted by C� Datef <br /> * Date Final inspection by <br /> { Pit or Grout Inspection by .. j <br /> f Additional Comments: ❑ Manteca 823-7104 ❑Tracy 835-63M t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621stk., CA 95201 <br /> Applicant Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave.,AP.O. Box 2009, j <br /> r PERMIT A' f <br /> � CK RECEIVED BY DATE ^' <br /> C FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> 3,5: d � R7� <br /> i { + EH 13-24(REV•+/951 <br /> EH 1425 <br />