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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. � , <br /> 1601 ETelephoneN(209),4b6�b78�N, GA <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) f <br /> -Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> uin <br /> described. This application is made inncompliancLocaihSan Health DQstrictunty Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulatio o t e Subdivision Nam <br /> Phone _ <br /> Job Address Address <br /> Owner's Name ,l Phone <br /> Contractor's Na License No- <br /> b' <br /> TYPE OF WELL/PUMP WORK: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ ' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. �_PROP. LINE <br /> DISTANCE i0 NEAREST: SEPTIC TANK j— OTHER WELL �� PITS/SUMPS ti <br /> { FOUNDATION Imo!AGRICULTURE WELL <br /> 1CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> J Industrial J f-1 <br /> Open Bottom ❑Manteca Dia. of'Well Excavation ✓ <br /> 111 Dia. of Well Casing !,'1 <br /> Domestic/Private ❑Gravel Pack ❑Tracy <br /> ❑Public ❑D%"r ❑Delta Type of Casing <br /> Irrigation ; Approx. ❑Eastern Specifications S <br /> ❑Cathodic Protection Depth Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> H P State Work Ione <br /> Repair Work Done❑ Type of Pump <br /> j f <br /> Well Destruction ❑ Well Diameter Seating Material (top 50') <br /> Depth l Filler Material (Below 50`) <br /> �`fyPErOF SEPTIC WORK: NEW INSTALLATION ❑ EP ADDITION �No septic tank or seepage p�avaelableewithinu200cfee e),.j*s <br /> �hstallation will serve: .Residence Commercial they t. T_ �q�'" <br /> Nam6erof living uni.tss'v+ Number of a rooms Lot sizeWazer tah`le depth --,lD� - <br /> I Character of soil do a dept fof 3 feet: No• Com artments <br /> x '� Capacity i , P <br /> SEPTIC TANK _❑ Type/Mf9. Method of Disposal <br /> PKG. TREATME 0?. ❑� J-pe%f9 , +r Capacity �_ <br /> t - PProperty Line <br /> SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation y <br /> DESTRUCTION a <br /> 'Tota1 length/size .."F' <br /> LEACHING LINE ❑ No. & Length of lines �-! <br /> FILTER SED ❑ Distance nearest: Well Foundation�' Property Line: <br /> De th Size Number ` _ y •:. <br /> SEEPAGE PITS P Line <br /> `�{" ,— : Property' — -/ <br /> I omps, Foundation �i <br /> l�,' Distance ko nearest: Well L_s�— <br /> DISPOSAL PONDS , J. <br /> 1 hereby cert0.if-y4I tlave.prepared,this application and that the work will be done in accordance v+ith San a�t�gin county <br /> ordinances, state laws, and tis ift regulations of the Sar, Joaquin Local Health District. <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the wlawsOr watch this <br /> permit is issued, I shall not'pemploy any person in such manner as to become subject to workman s compensation,lawsTo�..rk fornwhic <br /> Contractor's hiring or §ub-contracting signature certifies the following: "I certify that in the performance of.the work for which <br /> l this permit is issued, I shall employ persons subject to workman's compensation laws of California." L <br /> l The applica must Ca11 r al required inspections. <br /> Complete drawing verse Side. `� t <br /> Title: ] f Date., . <br /> Signed X - <br /> SOR P TME N USE ONLY a ❑ Stk 466.6781 <br /> Ap ' ation Accepted by _� � Area / <br /> �—�- � Lodi 369-3621 <br /> Additional Comments: ❑ Manteca 823-7104 <br /> .k Pit ,or Grout Inspection by LGA Date /-_� <br /> 1J Date --L :� KJ► ❑ Tracy 835_6385 <br /> Final Inspection by $c-- P.O. Box 2009, Stk., CA 95201 <br /> f Applicant - Return all copies to: tnv,ronmental Health ermit/Services 160] E. Hazelton Ave., <br /> '�" <br /> FEE BASE AMdUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> I INFO <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> r 14-26 - <br />