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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - 1601 E. 'HAZELTON AVE., ST CKTON, CA <br /> Telephone (209) 466-0781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> M <br /> Application is hereby made to the San Joaquin Local Healdr District for a permit to con truct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance W 549 for sewage or No. 1 for weft/pump and the Ryles and Regulations of the San Joaquin i <br /> 1 <br /> Local Health District. <br /> Job Address QQ Z r Lot Size / ,�B PM <br /> Owner's Name AA-4 .Ve'[I rr Address 2- ��� <br /> hone ;7 D <br /> Contractors AddressA-00 w License No. Phone 3 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENJT ❑ DESTRUCTION ❑ J i <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ &HER- " 4260ver al/ei/l <br /> DISTANCE TO NEAREST: SEPTIC TANK 7n,& _SEWER LINES DISPOSAL FLD. PROP. LINE 1 <br /> FOUNDATION ' AGRICULTURE WELL -OTHER WELL PITSISUMPS-- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI N SPEGIFECATION l, ZV <br /> ❑ Industrial LlOpen Bottom Ll Manteca Dia. of Well Excavation � oi3. of Well Casing <br /> I<Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications " { <br /> ❑ Public Other ❑ Dela Depth of Grout Seal �� Type of Grout I <br /> ❑ Irrigation 5,Approx. Depth ❑ Eastern Surface Seal I tailed by- <br /> Repair Work Done ❑ TyWof Pump H.P. State Work Done t� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 Z4q*�Y7AA142 �0 tr liC�1�M�� <br /> Depth H114;Material (Below 501. } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RREPAIR/ADDITION.❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ayaila*0 within,200 feet.) <br /> Installation will serve: Residences Commercial_ 'Other " ~ <br /> Number of living units: Number of bedrooms I" <br /> Character of soil to a depth of 3 feet: Water.table depth :r'. <br /> SEPTIC'TANK ❑ Type/Mfg _ Capaci No. Compartments <br /> 6 PKG. TREATMENT PLT. ❑ fiAeiFiod of-Disposal <br /> Distance to nearest: Wei Foundation Property Line <br /> v <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well^r� Foundation Property Line <br /> r SEEPAGE PITS' ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line y <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."-: <br /> Home owner or licensed agent's signature certifies the following: "J certify that in the performance of the''work for which this permit is issued, Ishall not a <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#w work for which this perm t is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." 111 <br /> The applicanr�rlus all for all eq red inspections. Complete drawing on reverse side <br /> Signed X I �+ /I/1�_ _ Title: Date: <br /> D TMENT USE ONLY <br /> Ap icaton A opted by r _ ".- Date, Area <br /> y/ inaE in pection by Date_ <br /> Additional CoMments: r `AS <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy. 835-6385 z�;- <br /> y �7.. <br /> ApplicanReturn all cppies to: vironme al alth P '/ ervices 1 E. Hit n Ave., P.O. Bpx 2009, Stk.,,CA 9520FEE <br /> 1 �? <br /> INFO AMOUNT DUE AMOUNT REMITTED ttK RECEIVED BY DATE PERMIT'NO.1 <br /> + EH 13-24(REV.ti 95) /&33 <br /> EH 14-25 !• II <br />