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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601-E. AZE T O AVE., STDCKTON, CA <br /> H <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br /> C I V D <br /> r (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the��er8i,,T¢��d. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the nd R u1i ¢ s of the San Joaquin <br /> Local Health District.. + N IRION ENTAL„ HEALTH <br /> PV 'Job Address 0 �`� tov City i Yi IT/SERVICES PM <br /> Owner's Name5A %—IA.�+ I N ,�� +V• Phone <br /> Contractor Address' © Z] License No'. 6Z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 <br /> r"- <br /> PUMP INSTALLATION .❑ SYS7EM`REPAIR ❑ OTHER L1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWEA-CINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE-OF WELL" PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑;Ope'n'bottom ❑:Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/_P.rivate s� ❑ Gravel-Pack 1. ❑tTracy Type of Casing Specifications <br />` f I?utilic- E l-Oiher w f l`Delta Depth of Grout Seal Type of Grout _ <br /> " `Irrigation 1; L Approxi ths DepI ] E stern Su1rfa a eat Installed by i = If <br /> Repair Work Done Type of Pump' i H.P. r � I� State 11.y,,k'Done)r <br /> ° Well Destruction .© Well Diameter -- Sealing Material )top 50'Fr. - <br /> • Qepth' i " '.5 " Filler Material (Below�50') " ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (') REPAIR/ADDITION,I l DESTRUCTION ! I (No septic system permitted if public sewer is O <br /> { " available within 200 feet.) <br /> 1. <br /> Installation will serve: Residence .�'Commercral Other <br /> Number of living units:, .. ;i1Numh'er of bedr oins <br /> Character of.soil to a depth of 3 fedti Water table depth <br /> 'SEPTIC TANK ❑ Type/Mfg :J. Capacity No. Compartments <br /> PKG.TREATMENT PLT. ❑ ' C Method of Disposal ' <br /> Distance to nearest: <,1NelI Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines y, t Total length/size <br /> FILTER BED ❑ Distaneb to nearest: Well ,- Foundation Property Line r <br /> I <br /> SEEPAGE PITS 11 Depth Size Number b <br /> r <br /> SUMPS 0 Distance to nearest: Vti1e1{? Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify, prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and re ations of th San Joaquin Local Health District. <br /> Home ow r or licensed ant's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not <br /> employ y person in su A manner as to become sub' to`workman Is compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifie the following:: ' ertify t at tn. r c of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion la s of Calif a <br /> I <br /> The plican my II for al r cti s. Compi a dra4ng on re <br /> I l Z/ <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> � JJ <br /> Application Accepted by ! Date Area <br /> I Pit or Grout Inspection by Date Final Inspection by Date L/ <br /> 1 - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 923-710 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Service0601 E-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> F <br /> INFO AMOUNT DUE[ AMOUNT REMITTED .CASH RECEIVED BY DATE PERMIT NO. <br /> +.EH124 IREV.t i m 51 ! �1 <br /> EH 14-4-2a 1 ^ <br /> J <br />