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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7601 E. HAZELTON AVE., STOCKT01 CA <br /> Telephone (209) 466-6787 <br /> F PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED <br /> Application is hereby made to the San Joaquin Local Health iCOit7 <br /> (Complete <br /> In Triplicate) <br /> made in compliance with San Joaquin County Local Health District. permit to construct and/or install the work <br /> ty Ordinance No.549 for sewage or No, 1862 for well/pump and the Rules herein described.This application is <br /> Job Address <br /> Regulations of the San Joaquin <br /> "� 9 6 0% rl__. _ city � <br /> Owner's Name �f��Y1 Lot Size <br /> Address �; <br /> Contractor Phone f;3 <br /> TYPE OF WELL.PUMP: Address I <br /> EW WELL ❑ License No. <br /> NI <br /> Phone <br /> PUMP INSTALLATION E3D <br /> WELL REPLACEMENT ❑ T <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ ESTRUCTION ❑ <br /> SEWER LINES OTHER ❑ <br /> FOUNDATION DISPOSAL FLD, <br /> INTENDED USE AGRICULTURE WELL ! -�- PROP. LINE <br /> TYPE OOTHER WELL <br /> F WELL PITS/SUMPS Y <br /> ❑ Industrial PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca fr <br /> ❑ Domestic/Private ❑ Gravel Pack Dia' of Well Excavation 1 <br /> ❑ Public ❑ Other E3 Tracy Type of Casing Dia. of Well Casing <br /> ❑ Irrigation ❑ Delta depth of Grout Seal Specifications ' <br /> Repair Work Done EJ <br /> --Approx. Depth ❑ Eastern of Seal Installed by T °f Grout <br /> Type of Pump � H.P. <br /> Well Destruction ❑ Well Diameter State Work Done <br /> --�- <br /> Depth Sealing Material (top 50') 0 <br /> Filler Material (below 50'1 <br /> TYPE OF SEPTIC WORK: ' <br /> NEW INSTALLATION ❑ REPAIR/ADDITION ❑ <br /> installation wilt serve: Residence _ DESTRUCTION ❑ (No septic system <br /> Number of living units: Commercial Other' <br /> available within 200 feet.) if public sewer is <br /> Character of soil to a depth of 3 feet:bar of bedrooms <br /> SEPTIC TANK L2Type/Mfg Water table depth , <br /> PKG. TREATMENT PLT. ❑ <br /> Capacity---. No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation�L Property Line <br /> LEACHING LINE ���No-, g, Length of lines <br /> Well Q Foundation <br /> FILTER RED l - pistance to nearest: T�tal length/size <br /> � V <br /> - / <br /> SEEPAGE PITS ❑ Depth Property Line • <br /> SUMPS Size <br /> ❑ Distance to nearest: Number <br /> DISPOSAL'PONDS L1Well .Foundation <br /> —� <br /> I hereby ceProperty Line <br /> rtify that I have prepared this application and that the work willbe done in accordance with San Joaquin county ordinances s ' <br /> rules and regulations of the San Joaquin Local Health District. j <br /> Home owner or licensed agent's signature certifies the fo11ow1n tate laws, and <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> g: 'I certify that in the performance of the work for which this permit is issued, I shall not <br /> certifies the following:"I certify that in the performance of the work for which this t <br /> tion laws of California." Permit is issued,f shall employ g <br /> Thea P Y Persons subject to workman's compense- <br /> pp ant m t call r all requi nspections. Complete drawing on r rsa side. <br /> i <br /> Title: 2 <br /> Date: _ �C [ <br /> ��FORDE�PARTM�ENTUSE ONLY <br /> Application Accepted by <br /> Date � a� Ar <br /> Pit or Grout Inspection by Uma vrr <br /> Date Final Ins 1 �+J <br /> P i- Fo l a,,, Date <br /> 1 Faction by i` n <br /> Additional Comments: �, �'• P4,r, S � <br /> )(Stk 466.6781 Cl Lodi 369,1621 "p <br /> ❑ Manteca ❑ Tracy 835-6385 <br /> 823.7104 <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 <br /> INFO CASH RECEIVED BY GATE <br /> PERMIT`NO ((_ <br /> . <br /> E1113241REY,t(851 <br /> 76 ,--- L <br /> Eli 1428 ..� <br />