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' I APPLICATION FOR PERMIT <br /> ` �y1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j� 1601 E. HAZE�-T bN_'AV,E., STOCICTON, CA <br /> _ Telephone(209) 466-6781 <br /> �Q�¢ 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is fiereby m e to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin my Ordinance No. 549 for sewage or No 1862 for I pum nd the Rules and Regulatiohs of the San Joaquin <br /> k I <br /> Local Health District. A e L_, W <br /> � Cq`4^ - - //�t✓w City J� � Lot Size PM <br /> Job Address f <br /> r� �ddress fµs�F#hone <br /> Owner's Name <br /> t <br /> Contracto LV S Address 9 License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALI SYSTEM REPAIR INSTALLATION Ll <br /> DISTANCE <br /> E3 <br /> - rr <br /> DISTANCE TO-NEAREST: SEPTIC TANEWERiIINES` - '+ t E -DISPOSAL--FLD. - PROP. LINE <br /> 0 <br /> FOUNDATION € AGRICULTURE WELL _ - _� OTHER WELL PITS/SUMPS <br /> 1.,}/s 4 a <br /> NTE.NDED-USE-a.*.-- T.YP_E-OF._-US'!.E—LLL_ —.PROBLEM..AREA. CONST-PI�i CTIOiV_SP_ECIFICATIONS <br /> _ <br /> �� ❑ Industrial '� EJ Open Bottom [J Manteca Dia. of Well Excavation f Dia. of Well Casing _ <br /> ❑ Domestic/Private <br /> L] Gravel Pack ❑Tra y^ Type of Casing ^ Specifications ! <br /> F1 Public ❑ OtherClrDelta1h Depth of Grout Seal Type of Grout, <br /> I k Irrigation _.-Approx. Dep h l I Eastern Surface Seal Installed by _ <br /> Repair Work Done 0 Type of Pump ' H-P. <br /> State Work one <br /> Well Destruction Re,Well Diameter 0 Sealing Material (4ap 58')41,11 7sAGI� LX C�/HtP <br /> Depth I F.016F matakei <br /> TYPE OF SEPTIC WORK: NEW INSTA0L SON I I REPAIR/ADDITION l 1 DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 fee <br /> i <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of'bedrooms 0 <br /> t.) <br /> Character of soil to a depth of 3 feet: Water table depth ' r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> ti- <br /> PKG. TREATMENT PLT. ❑ <br /> t Distance to:n arrest: Well Foundation Property Lind <br /> LEACHING LINE ❑ No. & Length,of.lines �^ ' �a ,TotaltiRlength/size <br /> r FILTER BED Ll Distance to nearest: Well Foundation,'' ��` Property Line It <br /> r.F <br /> SEEPAGE PITS I i Depth k Size Number <br /> ' <br /> SUMPS LDistance to nearest: Well Foundation Property rtYLine F <br /> � <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application 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 /> Homeowner o ense ant's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any rson in such annex as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the ollowing: "I ce ify that in the}perf an f the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws Califo nia." <br /> The appli nt mu c or requi to drawing o ev rse side. <br /> Signed X Title: .� Date: 11 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by � Date �CF- Area <br /> Il Pit or Grout Inspection by Dae Final Inspection by ate P 4045� <br /> Additional Comments: <br /> El Stk 466-6781 C3 Lodi -3621 E3 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 /> I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVE{) BY DATE PEjRM^IT NO. <br /> r ♦.EH 13-24 tREV.1/a b7 O/ 11 O ^:i <br /> EH 14-29 <br /> — n� <br />