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t. <br /> APPLICATION FO IT <br /> "Pu-✓�. r SAN JOAQUIN LOCAL HEAL DISTRICT <br /> 1601 E. HAZEL T ON AVE., STO XTON, CA <br /> �t Telephone (209) 466-67: 1 <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. <br /> Job Address City!M L'',tW Size PM <br /> Owner's NameAddress c., a,V't Phone <br /> Contractor's Name / `CL L e V +� �(. License No. c C e Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> PUMP INSTALLATIOY ❑ SYSTEM REPAIR )Z OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -PITS1SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of.Grout <br /> ❑ Irrigation ---Approx. Depth �,❑ Eastern Su fiace Seal Installed by <br /> Repair Work Done Type of Pump �*_ H.P. [ _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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 /> The appli mus call for all require i pact* ns. Co ate drawing on reverse side. �r <br /> Signed L Title: ����� - Date: <br /> .,.,., FOR DEPARTMENT USE ONLY <br /> Application Ac��ddby .S . CAI,.S1 Date Q ,Q' Area <br /> Pit or Grout Inspectpri by Date Final Inspection by �, ;.r,• <br /> Additional Commenfs: — <br /> ❑ Stk 466-6781_7,' ❑'Lodi 3&*1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Retur'blelit copie§to E rdhmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> -� <br /> IF .r K7MOUNT 4UE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> N... 1 p�� pp��rr^gg <br /> +EH 13-24(REV.10/83) <br /> EH 14.28 <br />