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x � APPLICATION rOR PERMIT <br />} SAN JOAOUIN LOCAL E HEALTH <br /> DISTRICT <br /> RCAT - <br /> 1601 E. HAZE I 1 g <br /> Telephone 1209? x-678 <br /> I. <br /> .; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,J.J 2 { <br /> f <br /> (Complete in Triplicate) application This is <br /> rmit to construct and/or install the work herein described {f; ' <br /> for sewage n No'186'L for welllpump and the Rules an ERIJII�/SERI�ICES <br /> Application is hereby made to the San Joe Ordinance Nto.D549 fOF istrict for a pe . <br /> made in compliance with Sian Joaquin County <br /> FM <br /> Local Health District. Lot` �� Lot Size <br /> City <br /> Job Address I SDD �a Phone <br /> I C a-Ye Al$ ss �`2 <br /> Owner's Name �J License No.� "-Phone <br /> f^ Address DESTRUCTION D <br /> Contractor NEW"WELL WELL REPLACE ENT ❑ OTHER ❑ ' <br /> TYPE OF WE PUMP <br /> REPAIR E1fY_ pROp• LINE <br /> PUMP lNS7ALLATION ❑ DISPOSAL FLD._�p_ PITSISUMPS <br /> t SEWER LINES —� <br /> AGRICULTURE WELL OTHER WELL <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> FOUNDATIO <br /> YTYPE OF WELL <br /> PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE Dia. of Well Excavation Specifications <br /> ❑ Open Bottom Li Manteca i <br /> ❑ Industrial X Tracy Type of Casing ® i Type of Grout <br /> Gravel Pack <br /> Domestic/Private � Depth of Grout Seal <br /> Q Other ❑ Delta <br /> r-1Public ❑ Eastern State Work pone <br /> ❑ irrigation Surface Seat/ installed by <br /> �pprox. Depth H.P. <br /> Repair Work Done ❑ Type of Pump <br /> �� Material 401350`1 <br /> Sealing <br /> Well Destruction ❑ Well Diameter Filler Material iBelow 50'1 rmiriad if public sewer is <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ <br /> REPAIRIADDITION ❑ DESTRUCTION ❑ awailable�withsn 200 feet.) <br /> i 1Other <br /> tallation will serve: Residence <br /> Ober of bedrooms <br /> Water table depth <br /> Number of IV, Nu <br /> No. Compartments <br /> Character of soil to a depth o Capacity Method of Disposal <br /> ❑ Type/Mfg <br /> SEPTIC TANK aLine <br /> ,) tion Property <br /> PKG. TREATMENT PLT. Weil <br /> Distance to nearest: 1— <br /> i Tota /size <br /> ❑ No. & Length of lines Property ----- J <br /> i LEACHING LINE ► Foundation <br /> FILTER BED ❑ Distance Well <br /> ce to nearest: <br /> Number <br /> Size---------- Property Line 1 <br /> + SEEPAGE PITS ❑ Depths Well Foundation <br /> r p Distance to nearest: <br /> f SUMPS,—DISPOSAL.PONDS ❑- -� -� -�" <br /> a re orad this application and that the work will ba done in accordance with San Joaquin county ordinances, <br /> lawssha, <br /> not <br /> I hereby certify that I have p P I certify that in the performance of the work for which this pe <br /> rules and regulations of the San Joaquin Local Health District. persons subject to workman's compensa <br /> Home owner or licensature <br /> ed agent's signature certifies the following:work for which this permit is issued,I shall employ pe <br /> " such manner,as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting sign <br /> l employ any person in rformance of the w <br /> certifies the following:'"I certify that in the Pe <br /> r tion laws of Calf rnia." Date: <br /> I The applic nt st call for all requi inspections. Co plate drawing r V r58 S <br /> r <br /> Title: ` <br /> l' Signed FOR DEPARTMENT U NLY <br /> Area <br /> c Date — <br /> � Date <br /> Application Accepted by <br /> Date � Final inspection by <br /> Pit or Grout Inspection by <br /> � ❑Tracy 835'6385 <br /> Additional Comments: ❑ Manteca 823.7104 Stk., CA 95201 <br /> F' <br /> ❑ Stk 466 6781 ❑ Lodi';369 3621 <br /> Applicant- Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. ox , <br /> I l DATE PERMIT"'NO. <br /> ASH RECEIVED BY <br /> FEE AIMVOUNT DUE AMOUNT REMITTED / +� <br /> INFO <br /> l + EH 1324(REV.11 a 5) � <br /> EH W28 <br />