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APPLICATION FOR PERMIT <br /> SAN JOAQUiN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE.,WOCKTON, CA <br /> Telephbne (209) 46676781 <br /> PERMIT EXPIRES-1 'Y�EAR FROM DATE ISSUED <br /> (Complete in Triplicate),, vftTB-till <br /> Application is hereby made 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 County Ordinance No.549 for sewage or No. 1862 for well/ <br /> Local Health District. iw" pum p and the Rules and Regulations of the San Joaquin <br /> 4, <br /> Job Address <br /> lcity A�404� Lot Size lk-)e tLAD <br /> PM <br /> 4)Owner's Name <br /> Address Phone- (071- <br /> ContractorAddress E.1-0S <br /> -License No.Z����.,Phone <br /> TYPE OFWELL/PUMV-, NEW WELL 0 WELL REPLACEMENT EJ DESTRUCTION 0 <br /> PUMP WELL <br /> E <br /> SYSTEM REPAIR E <br /> DISTANCE TO NEAREST: SEPTIC.TANK:11-- ! SEWER LINES' <br /> DISPOSAL FLD2. J 1-.r2­PROP1. <br /> LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPEOF' <br /> VV ELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 7--- <br /> EJ Industrial 0 Open Bottom ❑;Manteca <br /> Dia. of Well Excavation <br /> Domestic/Private <br /> EJ Dia. of Well Casing <br /> El Gravel Pack Ei pacy Type of Casing Specifications <br /> LJ Public Depth of Grout Seal <br /> D Irriof Grout <br /> gation --Approx. Depth Eastern Surface Seal Installed by Type <br /> Repair Work Done E Type of Pump H.P. State Work Done <br /> Well Destrucirion EJ Well Diameter Sealing Mate7ial"flap 50'j <br /> iI Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El <br /> DESTRUCT REPAIR/ADDITION I (No septic system permitted if public P6 sewer is <br /> available within 200 feet.) <br /> Installation Comme Other <br /> will serve: Residence X- Commercial 1. -> I <br /> Number-9f living units:-�aX-Number of bedrooms <br /> Character of soil to a depth-of,3, f�667-'-AZLV <br /> SEPTIC TANK <br /> Water table depth <br /> 9 Type/Mfg -rr�' CapacitY-41242JOL— No. Compartments <br /> PKG. TREATMENT PLT. C <br /> Distance to i Method of Disposal <br /> t �oundation- Property Line <br /> nearest: V <br /> LEACHING.-LINE No. & Length of tines <br /> Total lee ngth/size <br /> FILTER BED Distance,to-nea--est-..—..r-wiI t­­�Foundation--f'Property Line_ <br /> SEEPAGE PITS N Depth <br /> .'Numbbr <br /> SUMPS L] Distance to nearest: Well Foundation w1ifrop.:Property Line <br /> I hereby certify that I hive prepared this application and th t the work will be done in <br /> DISPOSAL PONDS 1 0 <br /> accordance'with San Joaquin county ordinances-, state laws, andi <br /> rules and regulations of the San Joaquin-1ocal,'Health District.. r <br /> Home ownerlor licensed agent's signature certifies the follow' in <br /> em !o ang: <br /> I certify,that in the performance f the work for which this permit is issued, I shall not <br /> loy y fol <br /> in sdch manner as to become subject to�,workman's compensation laws of California."Contractors hiring or sub-can' <br /> I �racting signature <br /> certifies the following:"I certify that in the performance of 6e work foi which this permitis issued, I shall employ persons subject to w <br /> tion laws of talifornia.­� r <br /> orkrinan's compensa- <br /> The applicant must call for all required inspections. Complete drawing on <br /> reverse sid <br /> Signed <br /> Title: <br /> Date: 1114- <br /> FOR DEPARTMENT TM ME <br /> NT USE' ONLY <br /> Applicati'6n Accepted by <br /> 01 Date Area <br /> Pi o �y <br /> Grout Inspection by Final Inspection <br /> Date <br /> Additional Comments: <br /> El Stk 46&-6781 Ll Lodi 369-3621 0 ManteicaX823--7-110(2�. 0 T-racy—83!�63% <br /> Applicant- Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 9 <br /> CASH RECEIVED BY, DATE <br /> PERMIT NC,,] <br /> E14 13-24(REV.1/9 5) <br /> EH M26 <br />