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APPLICATION FOR PERMIT MgCklAbO INC. <br /> IN LOCAL HEALTH DISTRICT <br /> SAN JOAO.0 247 NJack � <br /> Ton . <br /> i, Rd. <br /> 1601 E. HAZELTON AVE., STOGKTON, CA ������� Calif. ����7 <br /> Telephone (209) 466-6781 <br /> RMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is here q aJ( e n Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> Joaquin County Ordinance No.549 for sewage or No. 1862 for weii/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance <br /> Local Health District:' A <br /> r <br /> f y PM <br /> ` City <br /> Lot Size <br /> Job Address <br /> p„ Phone —� <br /> Owner's Name 1� r _ Address <br /> 5 <br /> License No. C) Phone k L XContractor's Name r!Y r �' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ -DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER LAY <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> p Industrial ❑ Open Bottom [I Manteca Dia. of Well Excavation Specifications <br /> ❑ <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> L1 Public El <br /> ❑ Delta Depth of Grout Seal _ Type of Grout <br /> - r� <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surf ce Seal Installed S CV1,`1V <br /> Repair Work Done I4�Type of Pumpf - - <br /> H.P. t State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (tap 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septiclable system <br /> m rmit ed if public sewer is <br /> i Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: 21 <br /> No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal C <br /> ' PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> Total Iengthlsize <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line - <br /> SEEPAGE PUTS � ❑ Depth <br /> 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, stats 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, 1 shall not <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 the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica call for all re i ctions. mplete drawing on revs} silo 5 r <br /> SigneELd <br /> Title: l _ Date: <br /> FOR DE ARTMENT USE ONLY <br /> Date 3/ Area / <br /> Application Accepted by _ <br /> Pit or Grout Inspection by Date <br /> Final.lnspection b Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 13 Tracy 83x6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> FEE CK RECEIVED BY DATE PERMIT"NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 1a24(REV.1010/81raV1 y/ 5 <br /> EH 1428 <br />