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7 <br /> APPLICATION FOR PERP"IT <br /> SARI JOA!]UIN LOCAL f EALTE STRICT <br /> 1WI E. HAZELTON AVE., STOC TIC ON, CA <br /> Telephone (209) 466-6781 <br /> PEPPAIT EXPIRES 1 YEAR FRONA DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicatior,is hereby made to the San Joaquin Local Hmlth District for a perma to construct and/or install the work heroin described.This application is <br /> made in ceml,lianca with San,loa juin Country Ord,rmnce No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquo <br /> Local Health Dis:nct. <br /> ti �d Z� Ja'r�r� Cit ✓"fes Lot Size <br /> Job Address - -- `�-' PM -! <br /> Owners Name Add;ass __ a'� - Phone <br /> -Q . <br /> ( Contracto 1� °' Ia V�Address G? fps;%r- "a )cense No. a - oma <br /> TYPE OF WELL/PUMP: NEW WELL 1.) WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ,_ SEWER LINES DISPOSAL FLO. PROP LINE <br /> FOUNDATION _ AGRICULTURE WELL __ OTHER WELL PITS/SUM <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IndUSSrial CI Open Bottom ❑Manteca Dia.of V.',30 Excavation Die.of Wel!Caairtg <br /> C:l <br /> Domestic/Private ❑Grave)Pack ❑Tracy Type of Cnsing Specific&O*m <br /> p,,;bplc I-1 Other 11 Oeita Depth of Grout Seal Types of Grout _ <br /> I I Irrigation _Approz. Depth 1 1 Eastern P Surfae:a Seal Installed by <br /> Repair Work Done ' Type of Pump H.P,Pte- _ State Work Dorw _ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 1 <br /> I Depth Filler Material(Below 50') _ -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I ! DESTRUCTIGN I I (No septic sntettt prtrmitfed i!pub it savrsris <br /> available within 200 feet.) <br /> Installation will rave: Residence— Commerciol J_ Other <br /> 0 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.Como�rtrrosttti <br /> PKG. TPEATMENT PLY.Cl Mcthod of Ditspimsal <br /> Distance to nearsst: Well Foundation Property LM <br /> LEACHING LINE Ll No.A Length of pings - — Total length/tsaze <br /> FILTER SED ❑ Distance to nearov: Well Foundation�__ Property Line <br /> SEEPAGE PITS I I Depth - Siae Number <br /> SUMPS Ll Distance to nearest: Well_ Foundatinn__— Property Line <br /> DISPOSAL PONDS Cl <br /> 1 hereby certify than 1 have prepared this application and that the work well be done in accofdanca with San Joaquin cow.ty ordnavNial,suit icy".and C <br /> rules rind re,ulations of the San Joaquin Local Health District. <br /> Homo CAT"r gr licerts0d VtIV3 segnatuta omtifins Cn fdlowing:"I ce:^Sfy that in the parformance of the worm for vdith thin ppm Is kand,I sdllaA not <br /> wn-,,-toy any pormin in such mc-nnar as to becorno cut;.ct to v:oAmsn',r_-,n7cnsation lavers of CLIfornia."ContrarWea hkkM of U . d&-d*" <br /> er 2i-a fe mt""112:"I cc;t;N tom,in the pnrforsnnnca of the vr,ork fcr:a,ticlt this Vwrnit is iatwed,1 shall otrploY P +tab;ct M watrAM'o <br /> tiara N.of Cali.r-eirs." <br /> 71w nup'i tis 4S 1 fc 'I requ rod inrp-coons.Cvmpleta drnwin0 on mvomo cid". <br /> Tial@:�i.dttf«P,y.�® Date: <br /> F 0 P Dy c^a m oY,^aZNT blear 0NLY <br /> ,p;.'=',ion Acct^°ad by of e� of <br /> f� �" .''``;,��x!e,=�' _ Date Aad, <br /> F <br /> Pit or Grcut lne;,:stinn bye Date Final Inspoction by to�T <br /> £.dpi:ora l CktFl=ntz: <br /> ❑St% 4rM-GrS1 0 Ladi <"`.'a''�2521 0 Minwce 923-71.0-1 ❑TrEcy f i-E u <br /> App%cam-Return c'I copra to:Environrrantrl Health Permit/Serv'scea 1b'01 E,Har€;ton Ave., P.O. Sox 20M,S*.,CA X201 <br /> FZE <br /> INF® AAfGUPAT DUE AMOUNT"_A9iTTCrJ CASH RECEIVED Or 6�DATE PEfiAtfT'ldQ. <br /> 'i44�rt61f{EM.rr nSr ice•, '� �' � D rJ t1 <br />