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APPLICATION FOR PEFt�11#'T _ '• <br /> SAN JOAQUIN LOCAL .HEAT THbISTRICT <br /> 1601 E. HAZEL—1 OK AVE., ST -781 , CA ' <br /> Telephone (209) 466-6781 k <br /> PERMIT EXPIRES'*YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i <br /> anlor install the work herein describe . Tis <br /> is <br /> cation <br /> Application is hereby made to the San Joaquin Local Health District for a permit to 1 $62 forcwellldpump and the Rules and Regulations of hhe Sanl Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage o <br /> Local Health District. $ ' <br /> city. <br /> Lot Sized �9"73 PM <br /> Job Address <br /> �] <br /> Phone <br /> Address <br /> Owner's Name r t L' 4 <br /> s _,.p- . �1id_A -.. ..License-Na � -Phone <br /> Contractor" -----Address-.- <br /> TYPE OF WELLLPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> E PUMP INSTALLATION L3SYSTEM REPAIR ❑ OTHER ❑ <br /> SEPTIC TANK <br /> -SEWER ��-�__. , <br /> DISPOSAL FED. PROP. LIN <br /> OISTANCE TO NEAREST: SE <­_- _�. <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> IN USE TYPE OF WELL PROBLEM AREAc CONSTRUCTION SPECIFICATIONS pia. of Well using <br /> Open Bottom ❑ MaInteca Dia. of Well Excavation r <br /> ustrial p Specifications. <br /> C] Ind I p- <br /> I t Type of Casing � I <br /> ❑ 60mestic/Private'„ ❑ Gravel Pack ❑ Tracy yp Type of Grout - <br /> ❑ Other ❑ Delta Depth of Grout Seal ; <br /> I`! P,ublic • - ` - <br /> I l <br /> irrigation c� _Approx. Depth l I EAtern Surface Seal Installed by � � - <br /> ' State Work Done <br /> Repair Work Done O Type at Pump H.P, <br /> - <br /> I Weii Destruction - ❑ Well Diameter; V Sealing Materia! flop 50'1 - 3 <br /> Depth. Filter Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION I]� REPAIR.ADDITION ;� DESTRUCTION l i a�ailabpeiwithin 20c'sY5 ern 4 feetit�ed ij public sewer is 4 <br /> ' I stallation will senre`r Residence Commercial . Other • . # ' , <br /> Number of living units: _JL;'' /Number of bedroomg' " y <br /> Water table depth <br /> Character of soil to a depth'of 1,6et: No. Compartments <br /> SEPTIC TANK ❑ Type/Mgr l *` Capacity <br /> {` Method-of Disposal <br /> PKG. TREATMENT PLT. O s .c Property.Line <br /> Distance toy nearest; etly Foundation r <br /> `� . y :o <br /> LEACHING TI i;`'�" VNo. & Length`of l est 4 `Total length/size <br /> q7y�' t'3�.�7Foundation � Property Line <br /> q Distanc. to nearest: » Well I <br /> FILTER BED <br /> 1 . Number " <br /> SEEPAGE PITS I I Depth Size ' o —�� <br /> f Foundation��.— Property Line <br /> SUMPS ❑ Distance to nearest: Weil L , <br /> DISPOSAL PONDS I <br /> I hereby certify that'l have prepared this application and that the work will be done in accord a twl h San Joaquin`'L'ounty ordinances, state laws, and <br /> rules and regulations of the San Joaquin <br /> eLCetll He lth District. <br /> trio. : "V certify thaLin the performance of the wo*for which ttiis permit is issued, I shall not <br /> Home owner or licensed agents g <br /> signature <br /> employ any person in such manner as to become subject to'workman's compensation laws of California." Contractnsti�rr�nbB t to'Workman's compensa <br /> certifies the following: 'I certify that in the performance of the work for which this permit issued,IhalV,employ pe, <br /> tion laws of California.', I <br /> Thelappiicant must call;for--. -re ed-inspections-Complete•drawing on reverse side. <br /> // Date: <br /> 1 Siged X Title: <br /> l FOR DEPARTMENT USE ONLY <br /> I j#w- '�r <br /> Date 4.ri.„ Area <br /> # Application Accepted by <br /> e Final Inspection by '`� Date <br /> Pit or Grout Inspection by date f t <br /> Additional Comments: ` <br /> ElStk 466-8761 ❑ Lodi 369-9621 ❑ Manteca 823 7104 C7,Tracy 835-6385 <br /> vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax <br /> Applicant - Return all copies to: En2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT �REMITTER "�'✓rCK` :... RECEIVED_BY,,,. ___DAT.E.....�..,,._PERM <br /> l3�N0,^ -�- ---• <br /> SUE;gy , _A'MOUNT <br /> *.EH 13-24 IREV.I <br /> EH 14-28 <br />