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w � <br /> _ - APPLICATION FOR PERMIT V <br /> SAN JOAQUIN LOCAL <br /> 1601 E. HA,ZELTON AVE., "STalolbAL <br /> IMUTH <br /> Telephone {209) 466-6781 c� 1 <br /> PERMIT EXPIRES 1 YEAR FROM DAV�L <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Heafth District for a permit to construct and/or install the work herein descrbsd.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for$swage or No. IM2 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 13,2- o W d1v <br /> Lot Size PM <br /> -€€ A.0 ti <br /> Owner's Name N 14 <br /> l 0 6,C Address 1 Z 1) W Phone ef Yd- /2 3/ <br /> Contractor �7V N _ prQ!!L/Ne Address-�- License No. -0 z t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ //�� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER�. LQt U" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> industrial ❑ Open Bottom ❑ Maniacs Dia. of Well Excavation 'I 2 r► Dia. of Well Casing - <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing_ 1: - f try <br /> ('I Public �thfr FI Delta Depth of Grout Seal _ e OpOE F F—T �� <br /> Of Grout <br /> I I Irrigation ! Approx. Depth I I Easter Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump S� ,P. State Done <br /> Well Destruction ❑ We" Diameter _ �� Seeing Material{top WI _ <br /> Depth� Fillet Material (Below SO1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is W <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE fines Total Wngth/size <br /> FILTER BED to WON Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 1_1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C] <br /> I hNsby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Was, and <br /> rubs and regulations of the San Joaquin Local Health Dilttrict. <br /> Home owner er licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shah not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California."Contractors 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 compansa- <br /> tion laws of California." <br /> The applicant call for all required Inspections. Complete drawing on revs side. J <br /> sow {A/�"u1'e' Title: Date � � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by I Data 16 Ares lv3z- <br /> rte' <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> O Stk 406 6781 ❑ Lodi 360-3621 ❑ Manteca 823.7104 ❑ Tracy 835.385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT 140. <br /> INFO <br /> ♦ Ell t3-11 IREV.I/n 51 <br /> EH 11-26 C Q <br />