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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E: HAZEL T ON AVE. <br /> TON, CA <br /> Telephone (209) 466--6781 <br /> PERMIT EXPIRES 7YEAR 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 made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Lecaj'.Healih District. r s application is <br /> N. n Joaquin <br /> Job Address <br /> } City Lot Size - <br /> Owner's Name M <br /> Address .z <br /> Contracto Phon <br /> TYPE OF W L/PUM ; se No. <br /> NEW WELL ❑ ELL REPLACEMENT Q one <br /> DE , <br /> PUMP INSTALLATION ❑ DESTRUCTION <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ <br /> �— SEWER LINES OTHER ❑ <br /> FOUNDATION --- DISPOSAL FLD. PROP, LINE <br /> INTENDED USE AGRICULTURE WELL OTHER WELL <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS` PITS/SUMPS <br /> . - ❑ Industrial Q Open Bottom ` <br /> ❑ Domestic/Private If Manteca Dia. of Well Excavation V <br /> ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> f"1 Public C1 Other Type of Casing <br /> [� Delta Depth of Grout Seal Specifications <br /> I I Irrigation , <br /> --.Approx, Depth I I Eastern • Type of Grout <br /> Repair Work Done ElSurface Seal Installed by <br /> Type of Pump H.P. c P <br /> Well Destruction ❑ Well Diameter State Work Done <br /> Sealing Material (top 50'} _ <br /> Depth <br /> TYPE Filler Material (Below 501) <br /> OF SEPTIC WORK: N11111 <br /> EW INSTA TION I 1 REPAIR/ADDITION I_I DESTRUCTION I I fNo se tic <br /> Installation will serve; Re idence P system permitted if public sewer is <br /> Commercial avaiiable within 200 feet.) <br /> Number of living units: Other - <br /> Number of bedrooms f <br /> Character of soil to a depth of 3 feet- <br /> SEPTIC TANKTYPe/Mfg Water table depth <br /> � <br /> PKG, TREATMENT PLT. ❑ Capacity No. Compartments <br /> Distance to nearest: Well Method of Disp al-- -- .-_ <br /> foundation�- property Line <br /> LEACHING LINE C1 No. & Length of lines C7 ! <br /> FILTER BED L7 Distance to nearest: Well 0 1 length/size <br /> � - <br /> oundation_ property Line <br /> I1 <br /> SEEPAGE PITS ` <br /> Depth Size <br /> SUMPS 0 Distance to nearest: Weil " Numbei .. <br /> DISPOSAL PONDS ❑ Foundation Property Line-'-- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the foilowin ordinances, state laws, and <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 /> 9; "I certify that in the performance of the work for which this permit is'issued, !shall not <br /> certifies the following:"!certify that in the performance of the work for which this permit is issued,I shall employ tion laws of California." g <br /> p y persons subject to workman's <br /> The applicant m s call compensa- <br /> I rey�'a ins ti ns. omplete ra mg on rev rse side. - <br /> Signed X <br /> Title: <br /> Date: <br /> �-- FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> or Grout Ins <br /> Dat Area <br /> Inspection by Date r� <br /> - — Final Inspection b O <br /> Additional Comments: Dat f b 3 <br /> EJ Stk 466-6781 ❑ Lodi 369-3621 <br /> Tracy <br /> Applicant- Return all copies to: Environmental Health apeermitca <br /> /Serycels 1601 EHazelton Ave., P.O. Box 2009, Stk., CA 55201 <br /> FEE AMOUNT AMOUNT DUE Y <br /> INFO NT REMITTED CK <br /> CASH RECEIVED BY DATE i <br />+ EH 13-241REV,i/K5) ] O J PERMIT'NO. <br /> EH 14-29 <br />