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APPLICATION FOR PERMIT <br /> SAN JOAQJIN LOCAL HEALTH DISTRICT PERMIT N0. -93—7 Y7 <br /> 1601 ETelephoneN(?AVE., <br /> (z09) 466-6781 <br /> CA <br /> PATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> for a to to No. 1862 for well/pump <br /> Application is hereby madeotoithe <br /> San <br /> iJoaquin <br /> Loca ancelw�ithlSanDJoaquin County pconstruct <br /> 0 dinanceNo. 549for dsewage or the work herein <br /> n is <br /> de <br /> described. This <br /> PP <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> >+J� ! �� Subdivision Name a•_S� <br /> Job Address B- Phone 9 <br /> +_C ��f y. Address o? >' Phone <br /> Owner's Name A D License No. <br /> Contractor's Name h W V1 e Y <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ �" <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ OTHER }J � <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR SEWER LINES DISPOSAL ILD. PROP. LINE <br /> PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER OTHER WELL <br /> FOUNDATION <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> PROBLEMnt AREA Dia. of Well Excavation <br /> ❑ Open Bottom ❑Manteca <br /> Industrial Dia, of Well Casing <br /> ❑ Domestic/Private ❑Gravel Pack ❑ Tracy <br /> ❑ Public [jOther ❑ Delta Type of Casing <br /> Li Eastern <br /> Irrigation Approx. ❑ Specifications <br /> ❑Cathodic Protection <br /> Depth Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> Other Surface Seal Installed by t} t <br /> State Work Done 3�^`-� <br /> Repair Work Done E] HP Type of Pump v_ 1 <br /> Sealing Material (top 50') � ] <br /> We}} Destruction F-1WellDiamefAr Filler Material (below 50') Y <br /> Depth <br /> REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ available within 20O feet.) ` ! s <br /> Installation will serve: Residence Commercial Other� � Lot size �1 <br /> Number of living units: . <br /> Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity � No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity ___�_.— Method of Disposal <br /> PKG. TREATMENT PET. ❑ Type/Mfg Foundation Property Line <br /> SEWAGE SYSTEM � Distance to nearest: Well <br /> DESTRUCTION Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> ❑ Foundation <br /> FILTER BED Distance to nearest: Well <br /> Size Number <br /> SEEPAGE PITS ❑ Depth �1 Property Line <br /> SUMPS ❑1 Distance to nearest: Well <br /> Foundation <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 <br /> that in the performance of the work for which this <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health iDistrict.h <br /> Home owner or licensed agent's signature certifies the following: "I certify erformance of the work for which <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmanl; compensation laws of California.' <br /> Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the p <br /> this permit is issued, I shall employ persons subject t workman's <br /> coingeonareverse side tion laws of California." <br /> The applic must call for all required inspections, P J Date: <br /> Title: <br /> Signed X �tk 466-6781 <br /> ,DE RTME � SE ONLY Area ���_ <br /> Application Accepted b ❑ Lodi 369-3621 <br /> Additional Comments: Date ❑ Manteca 823-7104 <br /> pit or Grout Inspection by Tracy 835-6385 <br /> MA1,0,..ti Date � ..' ZJ/ 1-- <br /> Final Inspection by P.O. Bax 2009, St k., CA 95201 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., PERMIT N0. <br /> AMOUNT REMITTED <br /> RECEIVED BY DATE <br /> FEE BASE AMOUNT DUE ��p <br /> INFO iC` 1 D a 11 00 <br /> �r 10182 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 ` <br />