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`. ..PLICATION FOR PEf;MIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. <br /> H <br /> AZ>wLt O <br /> N <br /> AVE. STO <br /> CK <br /> TO <br /> N <br /> CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR. DATE ISSUED FROM . <br /> (Complete in Triplicate) <br /> described.This a pficat;on is <br /> permit to construct and/or install the work herein dela p <br /> District for a pe San Joaquin <br /> 1 Health ions of the oa4 <br /> San Joaquin Lova Rules and Reguiat <br /> rpficat;on 1s heleby made to the or No.7862 for won and the <br /> k tde in compliance with;San Joalluin County Ordinance No.549 for sewage <br />,[ cal Health District. <br /> Lot Size. <br /> �b Address <br /> ' t <br /> Phone <br /> Address -+ 3rZZ <br /> ner s NameLicense NO_1�i JF7r!7-Z _Phon <br /> ontracttfuF'2 C Address <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> 11STANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES .�— DISPOSAL FLD_ PROP. LINE <br /> FOUNDATION � � AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ open Bottom ❑ Manteca Dia.of Welf f xcavation <br /> 7 Industrial <br /> T of Casing Specifications <br /> 7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type Type of Grout <br /> '} Public f7 Other t l Delta - Depth of Grout Seal <br /> f 1 Irrigation —Approx. Depth <br /> i ! Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type <br /> of Pump ".P. State Work Done <br /> Well Destruction ❑ Well Diameter -- FiltrSeating material atop 50') <br /> Depth Filter Material (Below 50'Y <br /> TYPE OF SEPTIC WORK: 11 N�INS TAL TION . PI.<'AIR/ADD11ION i I DESTRIICTION.1 l availaINo ble septic 200 feet.) <br /> if public sewer is <br /> Installation will serve: Residence Commercial they <br /> Number of living units: Number of rooms <br /> Water table depth <br /> Character'of sod to a depth of 3 feet: <br /> Type/Mfg Capacity No. Corppartrrlents I <br /> SEPTIC TAN / Methodi-of Disp t . <br /> PKG.TREATMENT Pt .© Property line , <br /> ' Distance to nearest:' Well. Foundation <br /> :LEACHING LINE o. &Length of!'rues <br /> �- To;al lengthlsk(i <br /> FILTER BED <br /> D Distance to nearest: Well F7udation — Property Line -- <br /> urr <br /> Depth Size timber <br /> SEEPAGE PITS i <br /> SUMPS Ll Distance to nearest. Well- Foundation_L_0 --t Property Line. <br /> DISPOSAL PONDS - <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin-county Ordinances. state Taws, and <br /> rules and regulations of the San Joaquin Local Health D&trict. I shall not <br /> `= Home owner or licensed Of <br /> agent's signature Certifies. following:"'1 certify that in the performance of the work for which this permit is issued, <br /> a n in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature N <br /> employ any fad persons subject to workman's comperm- <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued.i shall employ <br /> "'. tion taws of California." <br /> The applicant m 9 for an it . Complete drawing on reverse side. <br /> S <br /> Title: <br /> igned �_ Date <br /> E--. FOR DEPARTMENT USEONLY <br /> i Date I Area <br /> ' Pp <br /> A 1iration Accepted ny <br /> Q. <br /> �;eFinaal Inspection ate <br /> try r <br /> Grout Inspection by _ <br /> Additional Comments: <br /> S. [3Stk 465-6781 ❑ Lodi 369-3621 ❑ Manteca 823,7104 D Tracy 8358385 Stk.,-CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Servicas 1601 E. Hazelton Ave.. P.O. Box 2009, . <br /> CR RECEIVED By DATE PERM11•No. <br /> FEE' AMOUNT DUE AMOUNT REMITTED GASH <br /> INFO <br /> lot1324(REV.1 <br /> H 14-20 1 <br />