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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Q� `� � <br /> 1801 E. HAZE:T ne AVE., 6-6781 ON, CA ` ' 1 � &C lam, <br /> Telephone (209) 466-8781 (� <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. �CCj77 �J <br /> Job Address �'� Zbe ti-j-ejqA X City /-40 J I Lot Size J:g _oM <br /> Owner's Name - z­111y a Phone <br /> i Iy <br /> eJ <br /> Contrector'e Name License No. 2 a l/ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C <br /> Ir - PUMP INSTALLATION C r 'SYSTEM_REPAIR C OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISPOSAL FLO. 'PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CSNSTRUCTION SPECIFICATIONS <br /> C Industrial _ ❑ Open Bottom ❑ Massae Db. of Well Excavation Dia. of Well Casing <br /> C Dmiestic/Private C Gravel Pack Cl Tracy-J Type of Cubg Specifications <br /> C Public C Other ❑ Delta r-•. Depth of Grout Seat Type of Grout <br /> ❑ Irrigation sr __APprox. Depth C EestemSurface Sed Installed by e <br /> Repair llorWt Dore ❑ "Type of Pump H.P.:t- .State Work Dora <br /> Well Deehuction, C Wall Diameter . Sealing Materiel(top SD') _ <br /> 7- Depth 1- Filler Material IBelow 60') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITKIN ❑ DESTRUCTION❑-(No septic system permitted B public sewer is <br /> ' re. t, t /�fthi�n/200 f�ee�t.�! <br /> ` <br /> Installation will serve: Residence_ Commarcid—�tOther.A /V�-"- <br /> Number of living units: _. Number of bedrooms:—eL_ oe <br /> Character of soitto"a depth of 3 feet:- - Water table depth <br /> SEPTIC TANK Type/Mfg - Capacity Z2d✓ la No. COMParbnents <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Wag.7-04Z Foundation 1dr� _ Property Line S� <br /> LEACHING LINE X No. & Length of lines Told bn9ti+/siax `7d <br /> FILTER BED ❑ Distance to nearest: ; all yLt�Foundation ?Z6f Property U. <br /> SEEPAGE PITS . bt Optlm j_r� Size t4ttmhar <br /> SUMPS ❑ Distance to nearest: Well T6W ' Foundation ! Property Line_.44!2?! <br /> DISPOSAL PONDS• ❑ <br /> F I hereby certify that 1 have prepared this spplicadon and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rubs and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certlif es the following: •'I certify that in the performance of the work for which this permit is issued, I shah not <br /> employ any person in such manner as to become subject to workman's compensation laws of CelNomia."Contractor's hiring or sub-contracting sigrreture <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 workmen's compares- <br /> tion laws of Califomis." <br /> The appTica/rm�t�/'% II for aH requir`eed/''rmspo�_t ns. <br /> ornpbte drawin on reverse side. <br /> Signed X.(, � d�Fi—y bl>'+•`4 Title: 60 CL 0 +� Data: "">• `J <br /> / FOR DEPAflTM T USE ONLY <br /> /Application Accepted by Dam 7Arae <br /> /PitJor Grout Inspection by Final Inspection E� <br /> Additional Comments: <br /> C Stk 465-Ml C Lodi 309,1= ❑Mance 823-7104 C Tracy 835-6385 <br /> Applicant - "Unit all copios to: Environmental Naekh Permit/Services 1801 E. Hezehon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITMO 8 RECEIVED 9Y DATE PERMIrwo. <br /> INFO <br /> HI,121 IREV.111131 -1 Lj40 172 <br /> D ,42e <br />