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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STO , <br /> 'Telephone (209) x_678, CA No <br /> PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED <br /> (Complete in Triplicate) <br /> madeent compliance with San Joaquin nC County 0 dinance NJoaquin Local lo.549 for sewth District for s r n <br /> Local Health District. permit to construct and/or install the work herein <br /> .. , ., age or No. 1862 for weii/pump and the Rules and Regulations <br /> desThi a 1pn's <br /> C of the San J <br /> =t <br /> Job Address Joaquin <br /> SQ z <br /> C ity 7� <br /> Owner's Name /`. Lot Size PM <br /> �$ _ <br /> Address �- ` �z <br /> Phone [P <br /> Contractor <br /> TYPE OF WELL/pUMp; <br /> NEW WELL <br /> Li License No. / Q Phone �l4Jr'7d <br /> PUMP INSTALLATION ❑ REPLACEMENT EPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ DESTRUCTION El <br /> —�� SEWER LINES OTHER ❑ <br /> FOUNDATION —� AGRICULTURE WELL DISPOSAL FLD._ PROP LINE <br /> INTENDED USE TYPE OF WELL OTHER WELL— PITS/SUMPS <br /> ❑ Industrial PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Open Bottom ❑ Manteca L <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Excavation <br /> ❑ Public ❑ Other ❑ Tracy Type of Casing--________L_ Dia, of Well Casing. <br /> ❑ Irrigation ❑ Delta Depth of Grout Seal Specifications <br /> Repair Work Done ---Approx. Depth ❑ Eastern Surface Seal Installed by Type of Grout <br /> ❑ Type of Pump �1 H.P. <br /> .Well Destruction ❑ Well Diameter State Work Done <br /> Depth Sealing Material (op 50') <br /> p Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> Installation will serve: Rc septic system permitted if public sewer is <br /> Residence F v J <br /> �µ Commercial available within 200 feet.) <br /> Nu <br /> Number of living units: _ Other--- <br /> Numbermber of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth c. . <br /> PKG. TREATMENT PLT. ❑ Capacity--P <br /> No. Compartments <br /> Distance to nearest: t WellMethod of Disposal <br /> —� Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines' <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> Foundation property Line <br /> SEEPAGE PITS ❑" Depth } <br /> SUMPSSize Number <br /> ❑ Distance to nearest: ., Well l <br /> DISPOSAL PONDS ❑ Foundation Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances <br /> rules and regulations of the San Joaquin Local Health District: <br /> Home owner or licensed agent's signature certifies the following: rtify that in the performance of the work for which this permit is issued, I shall not <br /> , state laws, and r <br /> employ any person in such manner as to become subject to workman's compensation mpensation 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 em to <br /> tion laws of California." p <br /> A Y persons subject to workman's compensa- <br /> The applicant i call for all red inspections. Complete drawing on r erre side. <br /> Signed ' <br /> Title: <br /> k. Date: <br /> FOR DEPARTMENT USE ONLY t <br /> Application Accepted by 7 i <br /> DateArea <br /> Pit or Grout Inspection by <br /> Date_ Final lnspec- on by" <br /> r Date <br /> Additional Comments: <br /> El Stk 466.6761 ❑ Lodi 3611 E3 Manteca 823-7104 ✓ +i/ l S � f° i <br /> Applicant- Return all copies to:Environmental Health Permit/Services 1601 E.❑Hazel on Ave., P.O. Box Y009Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ' <br /> INFO C RECEIVED BY I <br /> DATE PERMIT"NO." ¢ <br /> EH 13-24(REV.t/851 <br /> EN%29 �p 4 i <br />