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APPLICATION FOR PERMITr j t� <br /> SAN JOAQUiN LOCAL HEALTH DIST Cq", <br /> 1601 E. HAZELTON AVE., STOC ?�04�y 6W" c .� �` PERMIT N0. <br /> Telephone (209) 466-67 1-: + DATE ISSUED <br /> \,t , �,' <br /> PERMIT EXPIRES i YEAR FROM QAT SUED <br /> l;l� Uri <br /> v� <br /> (Complete in Triplicate) �� 4t� E <br /> Application is hereby made to the San Joaquin Local Health District fora pew <br /> i awe <br /> and/or install the work herein <br /> described. tion is made in compliance with San Joaquin County Ord e No. 549 for sewage or No. 1862 for well/pump <br /> and the Rul s tions of.., the. San Joaquin Local Health District. <br /> Jab Address -h � bdivision Name <br /> Owner's'Name Address one <br /> Contractor's.Name <br /> Phone <br /> License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation- -- <br /> F-1wManteca - �-� <br /> Open Bottom ❑ <br /> Domestic/Private r-1GravelPack Tracy Dia. of Well Casing <br /> Public [—I Other Delta Type of Casing <br /> u Irrigation Approxi EJ Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout n <br /> LJ Other ( �J <br /> Repair Work Done FJ Type of Pump 1 H.P. State Work Dane ` I �Q <br /> Well Destruction U Well Diameter Sealing Material (tap 50') — <br /> Depth Filler Material (below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION (No septic tank ova seepage piavaelableed i fpublicwithin 200fsete)is <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Water table depth <br /> to a depth of 3 feet: <br /> Character of sail p <br /> SEPTIC TANK CJ Type/Mfg Capacity No. Compartments <br /> � <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity <br /> Property Line= <br /> SEWAGE SYSTEM � Distance to nearest: , Well. ..Foundation-. ,� r <br /> DESTRUCTION <br /> No. & Length of lines Total length/size <br /> LEACHING LINE U g <br /> FILTER BED . <br /> Distance to-nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number _�, ~ <br /> SUMPS �I Distande`to nearest; Well Foundation <br /> '� "'�ProPerty Line- ' <br /> v <br /> DISPOSAL PONDS. L7 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. this <br /> Home owner or licensed agent's signature certifies thesucfollowing:manner as to become subjectthat ntohworpkma��mcompensatance lionwlawsfof California."c <br /> permit is issued, I shall not employ any p <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whit <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." ' <br /> I The applicant ust c for all required inspections, Complete d wing on reverse side. Date: <br /> Signed X_ ] �u~ Title: <br /> ARTMLNT USE LY E] Stk 466-6781 <br /> Application Accepted by . Area <br /> Lodi 369-3621 <br /> j Additional Comments: Manteca 823-7104 <br /> Pit or Grout Inspection by Date ,/ <br /> Final Inspection by <br /> Date `�J-0 / Tracy 835-6385 <br /> Applicant.- Return all copies to: . Envi.r ntal Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 20D9, 5t k., CA 95201 <br /> L71 <br /> ASE AMOUNT .DUE AMOUNTREMITTED RECEIVED BYDATE PERMIT NO. <br /> / Z 4 <br /> + ` <br /> t , lolaz too <br /> k EH 13-24 REV. 10/82 <br /> r 14-26 <br />