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:M <br /> ', : <br /> ' APPLICATION FOR PERMIT _ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., <br /> X166 6781TON, CA <br /> r( <br /> Telephone <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 1lcation is <br /> is hereby No.549 for sewage or No. 1862 for well/pump and the flutes and Regulations of the San Joaquin <br /> • n made to the San JoaquinLoca1 Health District for a permit to construct and/or in the work herein described.This app <br /> Appli <br /> made in c <br /> made in compliance with San Joaquin County ordinance <br /> Local Health District. Lot Size r PM -- <br /> I City , ` <br /> Job Address U! Phone �L� /pD <br /> Address <br /> Owner's Name FfJ`— phone <br /> License No. <br /> 1101 rnP` <br /> Address pESTRUCTION ❑ �� <br /> oc or WELT REPLACEMENT ❑ <br /> NEW WELL OTHER❑ <br /> TYPE OF WELLIPUMP: - SYSTEM REPAIR ❑ ROP- LINE <br /> AW <br /> PUMP INSTAL ION y�, y DISPOSAL FLD ` <br /> SEWER LINES `�E- - OTHER WELL--PITS/SUMPS <br /> DISTANCE TO NEAREST-: SEPTIC TANK AGRICULTURE WELL <br /> FOUNDATION _ <br /> INTENDED USE TYPE OF WELL PROBL� EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of WeII Excavation Specifications <br /> ❑ industrial ❑ Tracy Type of Casing �n� <br /> ?}-Domestic/Private Gravel Pack /��C J _-- Type of Grout + <br /> .n Delta depth of Grout Seal <br /> f'1 Public <br /> r-1otheralled by <br /> Surface Seal Inst <br /> i I Irrigation �—,ApproState Work Done <br /> x. De�pth� t i Eastern <br /> Type of Pump H.P.Work Done Sealing Material (top 50'1 <br /> Well Destruction ❑ Weli Diameter -- Filler Material (Below 50') <br /> Depth tic system permitted it public sewer is <br /> available within 200 feet.] <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION l l REPAIRIADDITION t 1 DESTRUCTION I } {No sap <br /> Commercial____ Other <br /> Installation will serve: Residence <br /> —:.---=— <br /> Number of living units: <br /> Number of bedrooms Water table depth <br /> I Character of soil to a depth of 3 feet: Capacity� No. Compartments <br /> SEPTIC TANK, ❑ TypelMfg Method of Disposal <br /> PKG, TREATMENT PLT. ❑ Foundation Property Line <br /> I Distance to nearest: Well <br /> Total lengthlsize <br /> LEACHING LINE ❑ No, & Length of lines �... — Property Line <br /> ^� """`Foundation=_��� <br /> f M FILTER BED ❑ Distance to neare`sti"W We[I"' r <br /> Size Number <br /> SEEPAGE PUTS l 1 Depth Foundation Property Line <br /> SUMPS ❑ �Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> V hereby certify that i have prepared this application and that the work will be done in accordance with SJoauin county ordinances, state laws, and <br /> San q <br /> rules and regulations of the San Joaquin Local Health D-istrict. <br /> g work for <br /> Home owner or licensed gmanne gas torhecome subject following: <br /> workman'sify that in lawsoof California."aha Contractor's+hiri H1 or subcontract ngs permit is issued, l signature o <br /> employ any person in such <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> ` tion laws of California." <br /> st cal! for�rered insp t ns. Complete awing on reverse side.The applca <br /> III Y� <br /> Title: Date: <br /> [ Signed X <br /> E FOR DEPARTMENT USE ONLY nn <br /> DateArea <br /> Application Accepted by �L Date ' <br /> `• Pit or Grout Inspection by <br /> Date c� J�9— Final Inspection by <br /> G- Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3621 [1 Manteca 823-71A4 ❑ Tracy55 P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., <br /> T---- PERMIT NO. <br /> "".' <br /> CK- RECEIVED By OATS <br /> --FEE— ',4NfO-UNT DUE � AMaUNT EMI Et) CASH �[T� <br /> INFO r/(� _ (�(�f\`� � 3��' ` � ��� g'• <br /> r-EH 13-24'(REV..1/-15) <br /> EN 14-26 <br />