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,_ryv <br /> r- <br /> APPLICATION"FOR PERMIT. i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOWON# CA <br /> Telephone'(209)'466-6781 <br /> PERMIT EXPIRES1`YEAR'FROM•DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thisapplication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewageor No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. " <br /> Job Address 4_7,CRI� "!!,E e l City S 7*1V, Lot Size PIM 1± <br /> �w��� <br /> Owner's Name � ddress Phone <br /> Contractor Address._ �� WZZ- lld License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION j ,A,;y4e:—Y „REPAIR Ll OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 7 —' 7-OTHER WELL-' "”" PITS%SUMPS- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation '. Dia. of Well Casing <br /> ,VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing j Specifications p <br /> 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of-Grout, <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. E� State Work Done . 1EZ2 �,C%- e I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ s �,, 1 Z? L�U)7W Zs4r=w <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ADESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �4 � /, available within 200 feet.) J <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms Y <br /> Character of soil to a depth of 3 feet: I [Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity t No. Compartments i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ., � :1 <br /> LEACHING LINE ❑ No. & Length of lines <br /> g Total-length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 1 r�" Property Line <br /> SEEPAGE PITS ❑ Depth Size i Number <br /> •SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance'with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. ? L/ <br /> Home owner or licensed agent's signature certifies the following: ' <br /> g g g: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I R <br /> The applicantIIif all req ' pections. Complete drawing on reverse siple. ¢ <br /> Signed X 4V Title:_ c� J�Date: a <br /> ,12 FOR DEPARTMENT USE ONLYn Q I <br /> LApplication Accepted by Date ° � �» —F 5 <br /> Pit or Grout Inspection by Date Final Inspection by Dade �a <br /> Additional Comments: t" �+ <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 Q43 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEPEI 1 `NO. <br /> + EH124(REV <br /> .1/8b) 5 �Q r 'may Q <br /> EH 14.,26 � � <br />