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z. APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT19X <br /> 1601 ETHAZE..L.TON y4VESTOC66N CA <br /> Telephone (209)'466-6781 <br /> 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I U tl 0 <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 �WNMAAa�61ication is <br /> f made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the pVjfflpSWMe San Joaquin <br /> F Local Health District. <br /> I Job Address A/, A.0/91 100, City Size PM <br /> i I <br /> j Own is Nam G!d B K/ 6��• <br /> f Phone <br /> Contra o h ti 4+.•: Address License NoA Phone <br /> TYPE OF WELLIPUMP: NEO WELL F1 WELL REPLACEMENT ❑ <br /> DESTRUCTION ❑ _ <br /> PUMP INSTALLATION W- SYSTEM REPAIR ❑ OTHER ❑ N <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLb. PROP. LINE N <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> aInustrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> estielPrivate ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> f'1 Public l <br /> C1 Other ❑ Delta Depth of Grout Seal 7 a <br /> I I IrriType of Grout _gation _Approx. Depth 'l I Eastern Surfac I Installed by z <br /> Repair Work Done ( Type'of Pump _�� H.P. r� State Work Done <br /> y, <br /> Well Destruction ❑'� Well Diameter Sealing Material (top 50') <br /> ~ ' Depth - Filler Material (Below 50'1 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is <br /> t. r available within 200 feet.) <br /> 1 Installation will serve::;\Residence Commercial_ Other <br /> Number of living units: R Number of bedrooms <br /> 1 <br /> Character iof soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg . Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I <br /> i ! Method of Disposal <br /> y Distance to nearest: Well Foundation Property Line I <br /> (� LEACHING LINE ❑ "No. & Length of lines I <br /> $ g Total length/size <br /> FILTER BED E ❑ f-Distance tcnearest: Well <br /> t I Foundation Property Line <br /> t SEEPAGE PISS 1 I. Depth SizeNumber <br /> SUMPS` 4 ti 1 L] Distance to*newest:, ,_„Wel_l 1 Foundation Property Line <br /> DISPOSAL PONDSS t] s� . , ;- — <br /> 1 herebycertify <br /> that I ared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulati of the SA Joaquin'Local Heaith District. <br /> Home owner icensed agent's ignature'certifies'the,following: •9 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any erson in such man r as to bec a ubj _to orkman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies th following: "I certif hat in t ce o he work for which this ermit is issued, I shall employ persons subject to workman's compensa- <br /> tion law of California " <br /> The ap icant st 'allereq f om ate drawing on v <br /> Signed r <br /> at ,r <br /> Title: <br /> v e: <br /> Zo <br /> FO PARTMENT USE'ONLY <br /> Application Accepted by Date <br /> Area <br /> t <br /> Pit or Grout Inspection by I DateFinal Inspection by Date <br /> Additions! Comments: � ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH 13-241REV. Na) <br /> EH 14.26 35" <br /> tbU C,f <br /> k ! !c) 9d- /32 <br />