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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRIq` 3 "" <br /> 1601 ETelephoneN(209),466-678�N,'kCA PERMIT NO. g <br /> -DATE ISSUED <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'const 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 /> and the Rules and Re ulations of the San Joaquin Lo Health District. <br /> Job Address Subdivision Name <br /> Owner's Name AddressPhone <br /> Contractor's Name 177,10-H ., License No, Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑— DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR LJ OTHER ❑ <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 ❑ Manteca Dia. of Well Excavation <br /> Domestic/Private Ej Gravel Pack 0 Tracy Dia. of Well Casing <br /> ❑ Public ❑Other Delta N <br /> Type of Casing <br /> ❑ irrigation Approx. ❑ Eastern Specifications <br /> E] Cathodic Protection Depth <br /> Geophysical Depth of Grout Seal S, <br /> Other Type of Grout <br /> U <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fJ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is N <br /> available within 200 feet.) `] <br /> Installation will serve: Residence _ Commercial _ Other r <br /> Number of living units: Number of bedrooms Lot size <br /> U <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Cj Type/Mfg _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. �] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ED <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county �J <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of-Cil ifornia. <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant ust call for all req ired i pection Completed win on reve s de.. <br /> Signe Title: f Date: <br /> WENTSE ONLY <br /> Application Accepted by G,/ Ares` / �y Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection Date ❑ Manteca 823-7104 <br /> Final inspection by Date � Tracy 835-63B5 <br /> Applicant - Return all copies o. Environ ental Health Permit/Services 160i E. zelton 14/e., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO /!7 ' j' ❑ y <br /> )I S c �d "� g� ^7 -9 1ITK <br /> EH 13-24 REV, 10/82 10/82 500 <br /> 14-26 <br />