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r <br /> r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,cn, uA7G Tn111 AVC SjQCKTnnl C:A <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br />� . <br /> Application is hereby made to the San Jioaquin 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. 1 <br /> Job Address <br /> "1 �OI/ 4V F-• City Lot Size PM <br /> Owner's Name-ADP/ all r Y (4,5.1 Address(ZOe7 t° �j 000 V4 31 J z3 PhoneQ) 6S 71 <br /> Icv>tllw� `.� <br /> 1675 RISODN ROM Address License No. y>a 3_q Q Phone 49Y G <br /> Contractor <br /> I TYPE OF WELL/PUMP: .!NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ nnpp"� t� / <br /> PUMP INSTALLATION ❑ SYSTEM_3_� <br /> ❑ OTHER)K r�Ven �-`�We//j/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 2 DISPOSALFLD. PROP. LINE !: <br /> FOUNDATION �' AGRICULTURE WELL OTHER WELLPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z h° Dia. of Well Casing t ' <br /> i <br /> ❑ Domestic/PrivateGravel-Pack- L1 Tracy Type of Casing G Specifications S(o}', d•Q�`'L''' <br /> M Public Cl Other , C-1 Delta Depth of Grout Seal Type of Grout C­eN Ems. --. -� <br /> Q� 1i tfi! utj <br /> 2 j40WT,aJti A< ppro+. Depth 'r' Eastern Surface Seal Installed by 4 - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 r <br /> Depth `I Filler Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I- DESTRUCTION l I (No septic system permitted if public sewer is <br /> r available within 200 feet.l <br /> Installation will serve: Residence Commercial= Other �J' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> N41- <br /> 5- <br /> LEACHING LINE Cl No. & Length of lines Total length/size . <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth -Size Number <br /> `. <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line \ j <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:."{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 applicantt all for albepections. Complete drawing on r rse side. 1 <br /> C, <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by Date ( 0 Area <br /> Pit or Grout Inspection by "'"" Date/ Final Inspection by K'"- - Data <br /> Additional Comments: ' .6 e71-1 <br /> ❑ Stk 466-6781 ❑ L i -3621 ❑ Manteca -7104 ❑ Tracy E <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CKO i IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE ZPE�a+ EH 13-24 IREY.r/x 51 � �> V ? <br /> EH 1428 [CC/// - . uj_ <br /> ' <br /> LIUy 15 S_? - <br />