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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. jiAZEL T ON AVE., 6-6781 ON, CA ,:No <br /> Telephone {209} 466-6781 <br /> _T'31�� <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. C <br /> Job Address v City Lot Size x/1 PM <br /> r. 0 <br /> Owner's Name dress; Phone <br /> Contractor Address / License No.7� Phoned _ 2. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTAL ION ❑ SYSTEM REPAIR ❑ OTHER ❑ , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. E <br /> FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONS N SPECIFICATIONS <br /> ❑ Ind ustrial T ❑ Open Bottom © Manteca of Well Excavation - y— - -�^Dia.-df Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type o Ing Specifications <br /> Q Public Q Other Delta depth of Grout al Type of Grout F <br /> 9 <br /> ❑ Irrigation JAppro epth ❑ Eastern Surface Seal Installe <br /> Repair Work Done ❑ Typ Pump H.P. State ork Done <br /> Well Destruction ❑ ell Diameter s Sealing Material (top 50'1 <br /> x Depth Filler Material (Below 50'1 v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑IDES UCTION E-1 (No.septic system permitted if public sewer is <br /> S �� <br /> JCJ) able w'hin 200 feet.} <br /> Installation will serve: Residence'•? Commercial_ Other , r <br /> Number of living units: Number of bedrooms j µ r ray, <br /> Character of soil to a depth of 3 feet:" 1 ater table depth 0 l� <br /> E V. } <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT. ❑ ,�. N s Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t <br /> LEACHING LINE ❑ 3No:,&'Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS! ❑ Depth Size Number <br /> SUMPS ❑ 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. <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 /> emply 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 apl a must call all required inspections. Complete drawing on reverse side. <br /> I f <br /> Signed Title: 1p� R/LS Date: <br /> a FO DEPARTMENT USE ONLY <br /> PPS y 1*.Lo Q mb eN Date Area <br /> Application Accepted � g b �a� � ...,. ^� <br /> Pit orGroutInspection by y.,T Date Final Inspection by Date. f <br /> Addjtonal Comments:14 � ��'9� 9���,•,,,, b _ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT''NO. <br /> + EH14.24{REV.1/a 5t <br /> EH i4-26 <br /> 1 <br />