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| <br />| <br />' <br /> _ <br /> , <br /> � <br /> ` <br /> | <br /> ` <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 10 <br /> Telephone (209) 466-6781 <br /> Z17 PERMIT EXPIRES 1 YEAWFROM'D`ATE� <br /> ISSUED <br /> '(Complete in:Triplicate) <br /> stall the work herein desc i6ation is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in ribed.Tlvidiappl_ <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> 'Local Health District. <br /> Job Address t Zor 01Y. City &f7tf, Lot Size PM <br /> Owner's Name <br /> Addres —License No.- <br /> tractor & Phone <br /> TYPE OF WELL/PUMP: WELL REPLACEMENT 0 DESTRUCTION D <br /> NEW WELL <br /> PUMP INSTALLATION El SYSTEM REPAIR Ll OTHER 0- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLO.— PROP, LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL_� PITS/SUMPS <br /> INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTIOI� SPECIFICATIO S <br /> ks— <br /> Dia. of Well Excav Dia. of Well Casin <br /> 0 Industrial 0 Open Bottom LJ Manteca �ati P <br /> ravel Pack racy Type of Casing Specifications I&C/ <br /> I rAomestic/Private YT Type of Grout <br /> LD Public Ll 0 er 0 Delta Depth of Grout Seal <br /> tp <br /> E Irrigation TCApprox. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> I Well Destruction D Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 00 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EI REPAIR/ADDITION 0 DESTRUCTION 13 (No septic system permitted if public sewer is| available within 200 feet.) <br /> I.nstallation w ill serve: Residence— Commercial Other <br /> � <br /> Number of living' —'its:_ Number_ of bedrooms������ <br /> Character of soil to a I depth of 3 feet:- Water table depth <br /> SEPTIC TANK Type/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED Ll Distance to.near;st: Well Foundation Property Line <br /> SEEPAGE PITS _ Depth_ <br /> SUMPS 1], Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> | hereby certify that / have prepared this application and that the work will"edone ".""^""a ~.with San Joaquin county~ ordinances,_ state laws, _- . <br /> 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 permit is issued, I shall not <br /> ~� <br /> certifies the following:''/com�mutinm°n=�onmn�emm*"wvxmwhich mmu <br /> � n�nnmm .employ subject <br /> tion lawswCalifornia." ^ <br /> The applicant st cal )ections. Comil drawing on re <br /> Signed K_ Title: Date: <br /> FQ1J DEPARTMENT USE ONLY <br /> Date Area' <br /> ` Application_— Accepted -' <br /> Pit` _ Inspection <br /> ^�2JDatl:2�4_�� Final Inspection by Date <br /> �� ~ <br /> Additional Comments; <br /> D Stk 466-6781 El Lodi 3W3621 0 Manteca 823-7104 - 0 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIT-TED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> w-20 <br /> � <br />