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APPLICAT16 fOR",P.ERMIT <br /> SAN JOAQUIN-LOCAI,:HEA TH DISTRICT <br /> 1601 E. HAZEL T ON AVE:, ST&�KTON, CA <br /> Telephone (209) 466-67 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> b +r .. (Complete.in Triplicate) r <br /> Application is hereby made to the,San Joaquin Local Health District for a permit to construct and/or install the work herein 6scribed.This application is <br /> made in compliance with San Joauin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> �^ <br /> Owner's Name Y !"t't/ +P!/! Sem Address Y r� .M� P Phone <br /> .J ,o <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: i` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP.INSTALLATION ❑ SYSTEM REPAIR Pr OTHER ❑ <br /> DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS �t <br /> ❑ industrial ❑ Open Bottom r...- ..❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Ottier ~ ��❑ Delta Depth of Grout Seal Type of Grout <br /> F <br /> ❑ Irrigation —Approx. Depth Eastern Surface Seal Installed by <br /> Repair Work Done 1t9 Type of Pump r H.P. State Work pone <br /> Well Destruction ❑ Weil Diameter i Sealing Material (top 50') <br /> Dept ° Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Q (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units:__jJ Number of bedrooms <br /> Character of soil to a depth of feet: �' Water table depth <br /> SEPTIC TANK T ❑ Type/Mfg K Capacity No. Compartments # <br /> PKG. TREATMENT PLT. ❑ � ••; Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.�& Length of lines . 41 A t Total length/size I <br /> FILTER BED ❑ Distance to nearest: Well i F6und6;ti6n A. a Property Line <br /> SEEPAGE PITS ❑ Depth Size ^ Number <br /> SUMPS ❑ Distance to nearest: Well `'"`'Fo ndation Property Line i <br /> DISPOSAL PONDS ❑ <br /> l <br /> hereby certify that I have prepared this application and that the'.work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San lJoaquin Local Health District. E <br /> 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 fallowing:"I certify tO at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I'!i , <br /> The applicant mu"all for all required i ctions. mplete rawing on re side. <br /> Signed // I� Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by date Area <br /> i <br /> Pit or Grout Inspectio by INI Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk .466-6781 .❑ Lodi ._06 3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> o- <br /> INFO AMOUNIIT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br /> +EH 13-24 IRM 101831 <br /> EH 14.28 I V •J r <br /> - <br /> i I <br />