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APPLICATION FOR PERMIT <br /> .AN JOAQUIN LOCAL HEALTH DISTI... <br /> 1601 E. HAZELTON AVE., STOMON, CA <br /> Telephone (209) 466-6781 <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 Distrriictt. ` / , Qty <br /> Job Address ,./'��-I��/—`1 ry x`17 FIFE C S H I N C AJ t� r City s�GC IL t (9t Size PM <br /> me1�^ �IV U S 1,200 SWI 177'0 Si—. SLWFE IOSo // <br /> Owner's Na Address LAS Tr, N - T X `77oaL P11ori@4(3 65�77SS <br /> KVILMUG C- S 7 y/ — <br /> Contractor 1676 RISDON RDAD Addres License No. yji2.�C? Phone" <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �• SEWER LINES 3lo DISPOSAL FLD. PROP. LINE ,O <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ICp�— PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI0.lJS (` <br /> 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11Domestic/Private Gravel Pack ❑ Tracy Type of Casing vC" I Specifications y, <br /> I"1 Public ❑ Other ❑ Delta Depth of Grout Seal S LP.N4Qy,,.l <br /> P Type of Grout_. <br /> X/r-"`1p'11� igatr (� —.Approx. Depth 11 Eastern Surface Seal Installed by <br /> " Repaii Work Dona LJ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth �i C7 I Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if pubic sewer is <br /> available within 200 feet.) I <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING INE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 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 agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shah rwt <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or cab-contracting nature <br /> sig <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'sansa- <br /> sig <br /> tion laws of California." <br /> The applicant t call for a rr inspections. Complete drawing onyrey/�arsers'do. <br /> Signed X ;mrt <br /> ®/(Jf 7 Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> NFO CASH <br /> . EH 13-24 IREV.vev <br /> EH 14}a <br />