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APPLICATION FOR PERMIT <br /> SAN JpAQU1N LOCAL HEALTH DISTRICT <br /> ON, CA <br /> 1601 E. HAZEL i ON AVE., STOCKT1 <br /> I! Telephone (20g) 466-6781 <br /> I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <br /> (Complete in Triplicate) work .This application's <br /> uin Local Health District for a permit to construct and/or install <br /> the Rules and the (Regulations of the San Joaquin <br /> made to ttie San Joaq or No. 1862 for well/pump <br /> i Application is hereby Ordinance No.549 for sewage <br /> made in compliance with San Joaquin County <br /> Local Health District. I� 7� /)I,, S PM 1-- <br /> Ae (,y'r�fi City °� Lot Size; <br /> I Job Address Phone <br /> Address <br /> r Owner's NamePhone <br /> Address ,60D,Z �Ltt' °»! fidf, License NO._�---- <br /> `t 4, DESTRUCTION ❑ <br /> L Contractor WELL REPLACEMENT ❑ <br /> II NEw WELL_❑ `r OTHER ❑ <br /> ` t TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE <br /> r PUMP INSTALLATION ❑ DISPOSAL FLD. <br /> ;1! SEWER LINES PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> -FOUNDATION ��— <br /> I # TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE{CATIONS Dia. of Well Casing J <br /> INTENDED USE I ❑ Manteca Dia. of Well Excavation <br /> ❑ Open Bottom 1. Specifications <br /> ❑ Industria! l ❑ Tracy Type of Casing , 1 <br /> Domestic/Private ❑ Gravel Pack Type of Grout ---- l" <br /> M Public ❑ Other <br /> n Delta Depth of Grout Seal <br /> TM <br /> � ..Approx. Depth I I Eastern Surface Seal Installed by <br /> I I Irrigation H P State Work Done <br /> I Repair Work Done L] Type of Pump A , <br /> ❑ <br /> Well Diameter <br /> Well Destruction Sealing Material (top 50'1 — <br /> Depth Filler Materia! (Below 50') <br /> t TYPE OF SEPTIC WORK: ^NEW INSTALLATION REPAlRlADDITION I 1 DESTRUCTION 1 I availabPelwithin 200 fact,) if public sewer is <br /> Installation will serve: Residence J Commercial— Other I <br /> �M +� Number of bedrooms i ADO <br /> Number of living units: f Water table depth <br /> Character of soil to a depth of 3 feet: I�QQ No. Compartments <br /> —SEPTIC TANK L1 Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. 0 �017 10 <br /> r '! Distance to nearest: Well 0 Foundation �� � Property Line <br /> ^v &0 ° Total length/siie�� <br /> LEACHING LINE 0 No. R Length of lines e <br /> �� <br /> 'FILTER BED CJ Distance to nearest: Weil�✓�� r Foundation Property Line X00 <br /> .r SEEPAGE PITS Jf. Depth Size Number r <br /> SUMPS 0 Distance to nearest: Well f__ Foundation - Property Line <br /> DISPOSAL PONDS ❑ s <br /> I hereby certify that-(-have prepared-this application and-thatthe work will be dorie in accordance with San Joaquin county ordinances, state laws, and <br /> .'r rules and regulations of the San JoaquinfLocal Health District. <br /> �r 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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> l.' tion laws of California." <br /> 1 The applicant must all tor all required inspections. Complete drawing on reverse s ide. <br /> l Signed r i ��` [ <br /> — Y_ <br /> Title: bate: <br /> D <br /> FOR DEPARTMENT`USE ONLY 7 <br /> Application Accepted by i Date Area / <br /> Pit or Grout Inspection by Date Final inspection b _ Date <br /> Additional Comments: 11 z`"-~ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 CI Manteca. 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Silk., CA 95201 <br /> { i <br /> i� r <br /> FEE AMOUNT DUE MOUNT REMITTED CKSH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 1324(REV.i i n 5) <br /> EH 14-25 <br /> II <br />