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I. U <br /> t <br /> APPLICATION.FOR PERMIT '4' <br /> SAN JOA <br /> OUIN LOCAL HEALTH DISTRICT t ., <br /> 1601 E. HAZELTON AVE., STOCK <br /> -6781 N, CA <br /> Telephone (209) 4fi6-6781 <br /> I, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ ,� y..•, ;• <br /> I (Complete in Triplicate) application is <br /> Application is hereby made to the San Joaquin Local Health <br /> Ordinance No.549 far sewage or No. 1862 for well/pump.and the Rules and Regulations of the San Joaquin <br /> C <br /> District for a permit to construct and/or install the work herein described. s <br /> 1 made incompliance with San Joaquin'County . ., Y <br /> } Local Health Qistrict.,,,, City <br /> PM <br /> Q lti A goo rS Lot Size <br /> F Job Address <br /> IC 4 E c,vim F+2� of i Address <br /> Owner's Name <br /> `��' Phone <br /> License No. <br /> Contractor's Name WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> NEW WELL OTHER ❑ t <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE <br /> PUMP INSTALLATION ❑ 2 D DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK ��.SEWER LINES � PI7SlSUMPS �— <br /> AGRICULTURE WELL OTHER WELL— <br /> FOUNDATION -1-3_0 V <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATID S Dia of Well Casing <br /> pen Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ In ustrial IKo Type of Casing Specifications 10 J <br /> omestic/Private ❑ Gravel Pack <br /> ❑ Tracy Type of Grout <br /> ❑ Other - 0 Delta Depth of Grout Seal ' <br /> ❑ Public Surface Seal Installed by <br /> El Irrigation ---Approx. Depth ❑ Eastern 10 State Work Done <br /> Type 5 r <br /> Repair Work Done ❑ T YP of H.P.Sealing Material (top 50'1 Pump � <br /> k ,. <br /> Well Destruction ❑ Well Diameter �-- Filler Material (Below 501 ti <br /> Depth ermitted if public sewer is <br /> f TYPE OF SEPTIG WORK: .NEW INSTALLATION ❑ REPAIRlADDITION ❑ DESTRUCTION ❑ available within e200 feet.) <br /> G -- <br /> installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity—.1 No. Compartments <br /> i SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ _�-- <br /> Property Line <br /> 4 Distance to nearest: Well Foundation <br /> L Total length/size <br /> LEACHING LINE ❑ No. &Length of lines property Line <br /> I FILTER BED ❑ Distance to nearest: Well <br /> ation�� <br /> Fo <br /> ' Number <br /> ❑ Depth Size <br /> SEEPAGE PITS Foundation�— Property Line <br /> SUMPS L] Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> ' I hereby certify that 1 have prepared this, and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> 4 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, 1 shall no <br /> tion <br /> s of California-"Contractor's <br /> ring or sub-contracting signature <br /> employ any person in such ertan=hat n the performance subject <br /> to he workman's <br /> ork which th*rnpenis permit <br /> tion <br /> issued,shall employ persons`subj ct t workman's ompensa- <br /> certifies the following:"I certify <br /> tion laws of California." �GC mplete drawingon reverse side. <br /> ' <br /> I The applic ust call for all r ired ins ction <br /> � Date: <br /> Title: + <br /> a Signed - <br /> ;} FOR DEPARTMENT USE ONLY <br /> ttj;�;7Da�tQ <br /> �FinlInspection by Date � Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> 0 Stk 466-6781 0 Lodi 369-3621 <br /> lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952 <br /> 01 <br /> Applicant- Return all copies to: Environmental Hea <br /> CKRECEIVED BY DATE PERMIT"NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH i 1 <br /> INFO <br /> +EH 13-24 1pEV.101831 - <br /> F EH 14-28 e—V'— <br /> - b'--s-S --- _ _- <br />