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APPLICATION FOR PEi?M1i` <br /> SA.N JOAQUii-s LOCAL HEALTH DiSIRRC y ERh1IT NO, <br /> 1501 E. HAZELTON9],460678 'U A ATE ISSUED <br /> Telephone (2 1 � <br /> PERMIT EXPIRES 1 YEAR FROM DATE 0 <br /> (Complete in Triplicate) t ^'a1 A1! al} the work herein <br /> d��ar�. *n1g ���e or No. 1862 for well/pump <br /> Application is hereby made to the San Joaquin <br /> iLoce wHthlSanth DJoaquin Countyp rRlG1t�`i'1 <br /> described. This application is made in comp <br /> and the Rules and Regula#�ions_Pf,rhe sany)4aeuin Local Heal Subdivision Name phone �1 t <br /> Job Address— ' s Address t � � � <br /> A phone <br /> �Contractor <br /> �Name 7� Z� <br /> me <br /> i .... .,� a/�/L�IQ1License No. <br /> ISI WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> NEW WELL lA'.` OTHER U <br /> TYPE OF WELL/PUMP WORK: ` SYSTEM REPAIR ❑ pRpp, LINE v2 p <br /> pUMP INSTALLATION DISPOSAL FLD. 1— <br /> EWER LINES ^- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANKOTHER WELL <br /> - <br /> FOUNDATION AGRICULTURE WELL r <br /> CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL PROBL_ EM RREA <br /> INTENDEO USE ❑Manteca Dia. of Well Excavation <br /> Open Bottom <br /> Industrial Dia. of Well Casing ��—�— <br /> ❑ Gravel Pack ❑ <br /> Domestic/Private Tracy TEED <br /> ❑Other ❑Delta Type-of Casing <br /> ❑ Public Eastern <br /> Approx. EJ Eastern <br /> Irrigation DepthW <br /> ❑Cathodic Protection <br /> Depth of Grout Seal C6M 6-.7T� <br /> Type of Grout /�°+�� <br /> ❑Geophysical Surface Seal Installed by <br /> ❑Other <br /> State Work Done <br /> Repair Work Done Q Scaling <br /> Type of Pump l�— --�-- <br /> Well Diameter �_� Sealing Material (top 50') <br /> Well Destruction F1Filler Material (Below 501) <br /> Depth <br /> REPAIR/ADDITION J (No septic tank or seeavailable within 200 feet.) <br /> page pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U <br /> Commercial Other <br /> Installation will serve: Residence � � Lot size __��_— <br /> Number of bedrooms Water table depth <br /> Number of living units: <br /> soil to a depth of 3 feet: No, Compartments <br /> Character of <br /> Capacity <br /> SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Foundation . Property Line <br /> SEWAGE SYSTEM ❑ Distance to nearest: Well <br /> DESTRUCTION Total length/size <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> Foundation <br /> FILTER BED L] Distance to nearest: Well <br /> Size Number <br /> SEEPAGE PITS ❑ <br /> Depth ��_ Foundation Property Line <br /> sUMPS Ll Distance to nearest: Well _ <br /> ��� <br /> w 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 <br /> that in the performance of the work for which this <br /> Homenowner,ortlicensed�agentand rslsignaes turegcertifriesothehfollowingQu°I certify that <br /> District.' performance of the work for which <br /> permit is issued, I shall not employ <br /> any person in such manner as to become subject tthatrinathe perf rmanc laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify <br /> this permit is issued, I shall employ persons subject to mpletendrawoingeonareoversewSide.California." f /7 9� <br /> applicant St c 11 f al required inspections. Comp pate: <br /> The app Title: <br /> Signed XE 466-6781 <br /> F DEPARTMENT SE ONL�.ZArea � ❑ <br /> Application Accepted by Lodi 369-3621 <br /> Addition mments: ❑ Manteca 823-7104 <br /> Da�e �-' 835_6385 <br /> Pit or <br /> Or ut spection by pa ❑ Tracy <br /> 201 <br /> Final Inspection by <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box PERMIT09, CA 95 <br /> App DRTE <br /> AMOUNT REMITTED RECEIVED BY l <br /> FEE BASE AMOUNT DUE <br /> INFO <br /> 10/82 500 M <br /> I <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />