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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT209? 6KTON, CA G l.)"(( - 0 a f t f Cf <br /> Telephone78Ul cu�irs i,� (���' 0 r-'`` <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) applicationrk is <br /> all the wo <br /> Application is hereby made to the San Joaquin Local HNo.District49 for sewage or permit <br /> No. 1862 for well/pump and the Rules and herein described. <br /> of the San Joaquin <br /> made in compliance with San Joaquin County ordinance <br /> Local Health District. ,} PM <br /> CityF_Q <br /> E,O,t} Lot Size <br /> Job Address <br /> Q Phone <br /> Address O� ��� ` r7 �j�Z <br /> Owner's Name `7 �7.- <br /> Phone , <br /> f License No. <br /> Contractor's Name WELL REPLACEMENT DESTRUCTION <br /> TYPE OF WELL/PUMP: NEW WEL OTHER ❑ <br /> PUMP INSTALLATION,!. SYSTE REPAIR DISPOSAL FLD. Q F PROP. LINE l� <br /> DISTANCE TO NEAREST: SEPTIC TANK _7 SEWER LINES r PITS/SUMPS <br /> AGRICULTURE WELL OTHER WELL <br /> i" FOUNDATION <br /> TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial ❑ Open Bottom Specifications <br /> Gravel Pack ❑ Tracy Type of Casing Type of Grou <br /> ,(J <br /> `1q,DomesticlPrivate t- <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Public Surface Seal Installed by <br /> k ❑ irrigation ---Approx. Depth ❑ Eastern State Work Done <br /> Type of Pump _�� H.P. '1 <br /> Repair Work Done ❑ Sealing Material (top 50') pQ <br /> r Well Destruction ❑ Well Diameter Filler Material (Below 501 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Cl available'Within 200 feet.) if public sewer is <br /> I Installation will serve: Residence— Commercial— Other_ — <br /> Number of living units: Nurriber of bedroom_s Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type/Mfg Capacity�� <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT.❑ Foundation'__-: Property Line <br /> -Distance to nearest: Well , <br /> Totallengthlsize <br /> LEACHING LINE ❑ No. & Length of lines, -e to property Line <br /> FILTER BED El Distancnearest: Foundation <br /> s <br /> ❑ Depth <br /> SEEPAGE PITS Size Number <br /> Foundation Property Line <br /> I SUMPS ❑ Distance to nearesf""-'Well <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and thatthework will be done in accordance with San Joaquin county ordinances, <br /> re m tcssssued l shall not <br /> rules and regulations of the San Joaquin Local Health District. <br /> g <br /> nation laws of California."Contractors hiring or sub-contracting signature <br /> Home owner or licensed agent's signature certifies the followin 'I certify that in the performance of the work or which <br /> employ any person in such manner as to become subject to workman's comps <br /> certies the following:-I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> ' The applica st call for all required in c ions. Com le cawing an reverse side. pate: <br /> Title: (/ ` <br /> Signed <br /> 3. FOR DEPARTMENT USE ONLY <br /> Date — Are, <br /> Applic ceptey Date <br /> d bFinal Inspection by O ,} �Y al <br /> Pit oC Gro` I ction by ate v [ <br /> Additional Comments: Manteca 823-7104 ❑ Tracy 835-6385 <br /> ❑ Stk 466-6781 'p" ❑ Lodi 369-3621 Stk.. CA 95201 <br /> Applicant- Return all copies to: Environmental alth Permit/Services 160] E. Hazelton Ave., P.O. Box 2009, <br /> _ RECEIVED SY DATE _ w PERMIT"NO. <br /> .—. FEE AMOUNT DUE AMOUNT REMITTED CASH gs_ ] <br /> INFO v 3-2 <br /> +EH 1324(REV.191834 <br /> EH 1426 <br />