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Iq <br /> m�'gyy _ APPLICATION FOR PERMIT <br /> SAN .fOAQ IN LOCAL HEALTH DISTRICT <br /> :.. <br /> ,r w 1601 E. HAZEL i ON AVE., STOCICTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) applicationn described,This is <br /> Ie work <br /> here <br /> Application is hereby made to the San Joaquin Local He No <br /> made in compliance with San Joaquin County Ordinance District4for sewage or INo�1862 for cwe Itlpump and the Rules and/or install th 'Regulations of the San Joaquin <br /> Local Health.District. 114 iE <br /> city—A! t Size C2 PM <br /> Job Address , <br /> NIPl/ iidPhone <br /> Owner's Name I 4 <br /> �Qd nse No.Ylyr_4 El -Pho <br /> Contractor. Address J <br /> TYPE OWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR 11 OTHER ❑ <br /> SEWER LINES __Q_-DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OT PITS/SUMS ' <br /> FOUNDATION AGRICULTURE WELL <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e <br /> INTENDED USE Dia. of We <br /> ❑ Industrial ❑I Open Bottom D Manteca Dia. of Wel! Excavation Specifications' <br /> ' —Type of Casing <br /> ❑ Domesticl Private 0�Gravel ❑ Tracy Pack Depth of Grout Seal Type of Grout <br /> I"1 Public L7 Other Ll Delta _ <br /> �Approx. Depth l I Eastern Surface Seal Installed by <br /> I I irrigation State Work Done— <br /> Repair Work Done ❑ Type of Pump <br /> H.P. <br /> Sealing Materia! {top 50'1 v <br /> Well Destruction ❑ Well Diameter - <br /> :1, Fillet Material (Below 50.1 <br /> TYPE OF SEPTIC WORK: NEW IN5TALLATlON REPAIRIADDITION l 1 DESTRUCTION l i aNailabpelwithin 200 leets stem rt'ed if public sewer is h <br /> installation will serve: Residence Commercial_ Other <br /> F i m 1f�1 <br /> Number of living units: �p Numt�er of bedroo <br /> Water table depth <br /> Character of soil to a depth of 3 feet: (No. Compartments <br /> ❑, . ype/Mfg Capacity <br /> SEPTIC TANK TMethod of Disposal <br /> PKG. TREATMENT KT. ❑ / f' <br /> Distance to nearest: Well _ Foundation 1 Property Line <br /> F = Total length/size Q <br /> LEACHING LINE ❑ No. & Length of lines. <br /> �` Property Line 17— <br /> Foundation <br /> BED ❑ Distance to nearest: Well.�_ rf— Foundation <br /> r� Number <br /> SEEPAGE PITS ( I Depth 11 -Size //rte 1 Property LineR <br /> SUMPS Ll Distance to.nearest: I Well�� Foundation_An--- ` <br /> ,F. <br /> t DISPOSAL PONDS <br /> r hereby certify that'l 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. *•''` <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 signature <br /> shall note <br /> employ any person-in such manner as to become subject <br /> to <br /> work foswh chehss permiation t workma is issued,s of f/shall employ pe�sonsrs1ubjecng ti to workman!sgCompensa C <br /> certifies the following: 1 certify that in the pe 1\ <br /> tion laws of California. q� <br /> The applic m all for all req re inspecti ns. Complete drawing on reverse side. ` t <br /> ! pf/`—✓'0"4F> <br /> Signed X . <br /> �! Title: Date: <br /> j1 FO DEP SJE_...O.__NLY <br /> �P Date Area I <br /> Application Accepted by; <br /> 11 E� Final Inspection by Date 6 <br /> Pi or Grout Inspection by Dat _ <br /> _ f <br /> # Additional Comments: <br /> Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635 6385 <br /> 4 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> PERMIT'NO, <br /> FEE MOUNT DUE AMOUNT REMITTED 3 RECEIVED-BY DATE <br /> INFO S-7— 7, <br /> D J <br /> . EH 13-24 4REV. <br /> EH 14-26 <br />