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' APPLICATION FOR PERMIT <br /> -SAN .fOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL;T®IV•�QVE., STOCKTDN, CA <br /> Telephone {203) 466-6781 <br /> 1953 <br /> PERMIT <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> p H <br /> (Complete in Triplicate) <br /> Application is heieb1� �tp�lpr �Oaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in co°��1F ti tVq D unty Ordinance Na"549 for sewage or No" 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Dis�i � ! <br /> Job Address • I City Lot Size PM <br /> fir... Owner's Nam � � Address t. � <br /> ri AddressBPI MI-7 —License No. Phone <br /> ContractPA <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER F) <br /> SEWER LINES �3 DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL,"-,L <br /> Jf OTHER WELL PITS/SUMPS <br /> f: � f <br /> INTENDED USE TYPE OF;WELL PROBLEM AREA CONSTRUCT)bN SPECIFICATIONS <br /> Industrial <br /> L] Open Bottom El Manteca Dia. of WeII Eiccavatiori `� Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing..j ° r Specifications <br /> ❑ Public Cl Other I' ❑ Delta Depth of Grout S41 _ Type of Grout <br /> I I Irrigation `� L—Approx. Dept I ] astern Su ace Seal Installed by - <br /> Repair Worl Done &0 TImp' = H.P. State Work Done . <br /> Well Destruction•--- 0--•Well-Diameier---!" --'•""`-`"""" —Sealing-Materiah{top.50a� <br /> Depth 3 Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted it public sewer is <br /> 1. C available within 200 feet.) <br /> Installation will serve: Residence__ Commercial_ Other <br /> ' Number of living units: Number of bedrooms t <br /> ' f Water table depth <br /> Character of soil to a depth of 3 feet: <br /> i SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT" ❑ ,, ., ...,} Method of Disposal <br /> Distance to nearest: Well :h Foundation .r Property Line <br /> LEACHING LINE ❑ No. &Length of lines ) Total length/size <br /> r FILTER BED ❑ Distance to nearest: Well Foundation I Property Line <br /> SEEPAGE PITS I I Depth'- Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation i Property Line <br /> DISPOSAL PONDS ❑ 1`f <br /> ' I hereby certify that I ha a ared'this application and that the work will be done in tacaordance with San Joaquin county ordinances, state laws, and <br /> rules and regulatio of the San aquin Local Health District. f <br /> F �r' Home owner or tensed agent's sig ature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any son in such manner to beco su to en's compensation I9ws_9f California." Contractor s hiring or sub contracting signature <br /> ` certifies the Ilowing: "I certify th the ( r e e w for which this permit i •issued, I shall employ persons subject to workman's compensa- <br /> f tion laws o California.' c 11 <br /> The appiic nt m or at <br /> d ete 1.ng on revers s" ate:Signed ` <br /> FOR D ARTMENT USE ONLY <br /> Application Accepted by 3 t Date yt�~i�-1 �- Area ry <br /> Pit or Grout Inspection by I Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Silk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy/; 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton�Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO" <br /> INFO sem/{ <br /> } +•EH 13-20REV.1/mb) 'X <br /> t EH 16"26 <br />