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«7 <br /> APPLICATION.FOR PERMITe, <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> t i 1601 E. HAZELTON AVE., ON, CA <br /> Telephone {209} 466-67816-6781 � lltj �}rrp <br /> PERMIT EXPIRES '!'YEAR FROM DATE ISSUED �� � n <br /> (Complete in Triplicate) �1 <br /> Application is heFeby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein! This.application is <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 /> r Job Address 1 C1 y� ^� <br /> E `- rp��� City ` Lot Size PM <br /> Owner's Name a sss YL Address Phone <br /> - I <br /> Contractor S�4ddress- �� License No. q�l Phone <br /> - TYPE OF WELL/PUMP: ,NEW WELL ❑ WELL REPLA_CEMEN7-.C] DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 'i SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK r�SEWER LINES <br /> DISPOSAL FLD, �" PROP. LINE <br /> i FOUNDATION f AGRICULTURE WELL ' OTHER WELL PITS/SUMPS <br /> INTENDED USE J TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ' Dia. of Well Excavation - Dia.of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f"I Public ❑ Other 171 Delta Depth of Grout Seal <br /> I Irrii ation ri P Type of Grout <br /> J -- pro; Depth 17 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter, Sealing Material {top 501 i f <br /> Depth : Filler Material-(Below 50'1 'wT <br /> TYPE OF SEPTIC WORK: NEW'NSTALLATION-11—REPAIR/ADDITION I I DESTRUCTION Iseptic system permitted if public sewer is <br /> I <br /> Installation will serve: Residence— Commercial_- Other available within 200 feet.) <br /> Number of living units: Number of bedrooms z <br /> i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> -SEPTIC-TANK - •❑ ---Type/Mfg <br /> Capacity ----- <br /> P y"""" No. Compartments } <br /> PKG. TREATMENT PLT. 0 <br /> Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> " }LEACHING LINE ❑ ,No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property <br /> i 1 rs <br /> SEEPAGE PITS I I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L1a �Y„ <br /> hereby certify that I have prepared this application Arid that the work will be done in accordance with San Joaquin county ordinances, state laws, and - <br />_ rules and regulations of the SanJoaquin Local Health District. <br /> {emHome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issueshall not <br /> / pli9y d, !ny person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> Certifies th ollowing: ertify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- <br /> i tion laws of ornia-" - <br /> e applicant us all fora re fired i spec ns. G late drawing on reverse side...ti. + T <br /> Signed X <br /> Title- Date: w ' <br /> t . <br /> FOR RTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by <br /> Date _F-inal Inspection_by- _.Date. r <br /> Additional Comments: jp� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 oAim, J <br /> ��,kL�- P(r� W <br /> [��jzE <br /> vm)m nSmif of4- (41**A. <br /> FEE AMOUNT DUE AMOUNT REMITTEpa�- CKH .NFORECEIVED BY DATE a;PERN0.EH 1324 1REY,EH 14-26. � `� <br />