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APPLICATION FOR PERMIT - <br /> , 1,s - <br /> 44 <br /> SAN JOAQUiN LOLHcALTH DISTRICT ` !d�;a ''QC.� T�f <br /> 1601 E. HAZELTON AVE., STOCK70N, CA PERMIT N0.V ( y <br /> Telephone (209) 466-6781. ., <br /> DATE ISSUED 6. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 3-0 <br /> (Complete in Triplicate) <br /> Applicationis'hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein. <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or'No. 1862 for well/pump <br /> t and the Rules and Regulation of the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name ddress ..914 <br /> Contractor's Name �� icense No. "2-�1�,� . Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL r] WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK-] SEWER LINES DISPOSAL FLD, PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE' TY?E)OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i ❑ Industrial ❑Open Bottom ❑Manteca Dia.:of Well Excavation <br /> U Domestic/Private Gravel Pack ❑Tracy Dia' of Well Casing <br /> ❑ Public Other []Delta /Type of Casing <br /> Lj Irrigation Depthx C3 Eastern i, Spec ifi:caiaons. <br /> ❑Cet-iodic Protection P �•,� '� Depth of Grout Seal <br /> ❑Geophysical i <br /> ! Type of Grout <br /> ❑ ither �, e �f Surface Seal Installed by, <br /> DRepair Work Done []`*Type of PumpH.P State Work Done ' <br /> `, i 1 <br /> Well Destruction �j, Well Diameter Sealing Material (top,50.') ` <br /> ` Fi-lIer,;Materill"(Below 50'), <br /> �pepth .1--,--*,.1--,--*,I -, '' : <br /> bl <br /> TYPE OF SEPTIC WORK: NI:WiI,NSTALLATION LREPAIR/ADDITION 4(No septicaank-or seepage-piavailableewithinu200cfeet.) is <br /> installation will serve: Residence � ' Conmercial'-a. Other CZ-- / <br /> Number of living units: / Number of DLot size.edrooms 'z.% Water table depth G <br /> Character of soil to a depth of 3lfeet::� No. Compartments <br /> Capacity <br /> SEPTIC TANK ❑ Type/Mfg K- - - Method of Disposal <br /> Capacity <br /> PKG. TREATMENT PLT. ❑� Type%gam <br /> SEWAGE SYSTEM C3Distance to nearest: Well <br /> Foundation Property Line <br /> DESTRUCTION <br /> �Total length/size <br /> LEACHING LINE ❑ No.&iLength of lines Property Line <br /> FILTER BED <br /> ❑ Distance to nearest Well' FoundStion <br /> ❑ Depth 7� — Size A� Number <br /> SEEPAGE PITS P <br /> ` SUMPS U Distance to nearest: Well l e o Foundation !O Property Line <br /> r DISPOSAL PONDS ❑ <br /> ( that the work will be done in accordance with San Joaquin county <br /> I hereby certify that I have prepared this application and <br /> ordinances, state laws, and rules and regulations of the San Joaquin.Local Health District. <br /> Home owner or licensed agent's signature certifies <br /> suchfmannernas to become subjectthat ntohworkman�compensationnce o lawsofCalifornia."i <br /> permit is issued, I shall not employ any p <br /> Contractor's hiring or sub-contracting signature certifies <br /> the kman'slcomnensationrlaws ofaCaliforniat in the erformance of the work for which <br /> to P <br /> k this permit is issued, I shall employ P 2, ^GL <br /> - <br /> The applicant st call for all ired inspections. Complete draw] ion reverse side. Date: e <br /> Title: <br /> Signed X_ <br /> �AEDR DEPARTMENT US NLV Area �.� ❑ Stk 466-6181 <br /> Application Accepted by Lodi 369-3621 <br /> Additional Comments: Date ❑ Manteca 823-7104 <br /> Pit or Grout Inspection by DateI/ ❑ Tracy 835-6385 <br /> Final Inspection by / <br /> Applicant - Return all copies to: Environment Healtl�rmit/Services 1601 E. Hazelton Ave., P.O. Box 2009,:Stk., CA 95201 <br /> RECEIVED BY DATE PERMIT NO. <br /> FEE BASE AMOUNT DUE _AMOUNT REMITTED � <br /> 1Nf0 <br /> c�1 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> ,e ?r <br />