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APPLICATION FOR PERMIT <br /> I• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI_TON AVE., STOCKT_ ON, CA <br /> Telephone 12091 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 District. s rr <br /> Job Address � � Ci .r Lot Size PM <br /> -R �� � Oc�-C Phone <br /> Owner's Name Address <br /> c t ' g _ Phone <br /> Contractor's Na License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t <br /> i INTENDED USE - ' TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Y ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ <br /> Domestic'/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> © Public 11 Other Y� LiDelta . , Depth of Grout Seal Type of Grout <br /> C7 Irrigation k. �Approx�Depth ❑ Eastern `t Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> p Depth ' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 93-UESTRUCTION LJ (No septic system permitted if public sewer is <br /> 1 available within 200 feet.) <br /> Installation will serve: Residence= Commercial_ Other <br /> Number of living units:_�k Number of be <br /> A ms <br /> Ih Character of soil to a depth of"3 feat: - - --- Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT. 0 r, Method of Disposal <br /> E Distance to nearest: Well Foundation } Property Line <br /> LEACHING LINE .R" No. & Length of lines Total lengthlsize <br /> FILTER BED 4❑frD'i Lance to nearest: Well .52-f Foundation—/e!�3—.=-Property-Line-;5" <br /> SEEPAGE-PITS ❑ Depth. la/ Size / Number <br /> SUMPS" �YY Distance to nearest:' Well� Foundation /b f ^ Property Line S <br /> DISPOSAL PONDS ❑ <br /> 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 7 <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 /> 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 /> i <br /> The applicant st call for all qui d Inspections. Complate-drawing on reverse_si [// /�///�/r <br /> €'Signed T' Title: !!! r Date: <br /> II FOR REPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Grout Inspection by Date Final Inspection by Date <br /> ❑ Stk 46Cr6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104, ❑ Tracy $35-6385 {:�, '� - <br /> :Applicant- Retum all copies to: Environmental Health Permit/Services-160., E.�Hazelton.Ave TP.O. BoxZ00B, Stk:,;CA 95201 <br /> --�-^-^- FEE" -AMOUNT DUE `""-AMOUNT REMITTED' .TCK � "RECEIVED B`7 T DATE ' PERMIT"NO. <br /> INFO. <br /> GASH <br /> +EH 1324 inEv.10/831 - - - <br /> EH i4-26 <br />