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h <br /> APPLICATION FOR PERMIT <br /> " SAN JOAQUIN LOCAL HEALTH DISTRICT C}xtgt lY s'4 <br /> T <br /> 1601 E. HAZE I ON AVE., STOCICTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rAG [ w. � <br /> (Complete in Triplicate) r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the Q@ i� �plication is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the R+ 1Y1" �n Joaquin <br /> Local Health District. 6N��/ ttiiw <br /> Job Address ew <br /> , � /y City Lot Size PM <br /> Owner's Name ("ZIFO H_ - Address Phone <br /> 6177 . q <br /> Contractor Address o7fa?,eQ License No. �146 Phone f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP'LACEM€MT C-'-` --'--MSTRUCTFON—D'--- <br /> PUMP INSTALLATIONS ..J!VZ401YSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATON AGRICULTURE WELL -t OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial--0--Open--C]--Open-Bottom...—Cl-Manteca - ,.Dia- of,Well Excavation Dia. of Well,Casingt�V <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications <br /> t <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> i I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump :SN,5 H.P. __'__> -_ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <br /> Depth Filler Materiae-16 ow 50') ) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I, DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available`within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: f Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments <br /> PKG, TREATMENT PLT, 0 Method of Disposal. I <br /> Distance to nearest: Well Foundati'615 -� Property Line <br /> LEACHING LINE ❑ No. & Length of lines ` Total-length/size)' <br /> FILTER BED ❑ Distance to nearest: Well Foundation -:• Property Line <br /> A <br /> SEEPAGE PITS { I Depth Size _ -I-- Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t <br /> I 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 <br /> rules and regulations of the San Joaquin Local Health Dstrict. 1! <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, l 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." t I <br /> The applicamquir�C{-iryspg ns. Complete drawing on rave yside. <br /> Signed X9 Lam/// Title: Date: `� g <br /> 1 <br /> OP-D PARTMENT USE ONLY <br /> Application Accepted by I Date Area </ <br /> Pit or Grout Inspection by Data Final Inspection by Dat U <br /> Additional Comments: F <br /> ❑ Stk 466-6781 C1 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 /> INFFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVV�ED�BY CK 4 DATE PERMIT'NO. <br /> +.EH 1 <br /> 3-24{REV.r�H r, `-'.�' 1 ' 1t( �J—_2Q,311 <br /> EH 14-2e (/ <br />