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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L,,c!i 1601 E. WAZEL T ON AVE., STOGICTON, CA <br /> Telephone 12091 466-6781 . ., <br /> 3�—'LG/ / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TNs application is <br /> made in compliance with San Joaquin 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. r <br /> � 1 <br /> Job Address <br /> ��T� City �Z C� Lot Size � F ' PM � <br /> Ali C a PL Address- Phone _� <br /> Owner's Nam <br /> � <br /> e <br /> Phone <br /> Contractor's Nam <br /> s1't License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11I DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM_ REPAIR ❑ OTHER ❑ <br /> 5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> PROP. LINE <br /> -,4FOUNDATION �"'-'"`""AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA .CONSTRUCTION SPECIFICATIONS <br /> ❑industrial El Open Bottom 11 Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> F1 Domestic/Private Il Gravel Pack ❑ Tracy Type of Casing Specifications <br /> �4 .,. " Type of Grout , <br /> Ll Public C1 Other ❑ Delta Depth of Grout Seal yp x <br /> ❑ Irrigation —Approx. Depth -❑ Eastern Surface Seal Installed by <br /> Repair Work Done LiType of Pump H.P. State Work Dane <br /> Well Destruction ❑ Well Diameter I Sealing Material [top 501 Y <br /> ' Depth Filler Material (Below 501 .� <br /> ` TYPE OF SEPTIC WORK: 'NEW IN°STTA�LLATIO REPAIR/ADDITION El DESTRUCTION El (No <br /> sbltic system permitted if public sewer is S. <br /> ` <br /> (A <br /> Installation will serve: Residence`' Commercial= Other " <br /> Number of living units: Number of b drooms ` �� �tar�e <br /> SSS <br /> Character of soil to a depth of 3 feet: a►. otc"!� Water table depth l <br /> SEPTIC TANK - .�<c Type/Mfg opacity 4d No. Compartments 1 <br /> �; Cm+Ltr;i <br /> ��,Wq4_eo <br /> i Method of DisposalPKG. TREATMENT PLT. ❑ �� / �O <br /> . Distance to nearest: Well Foundation_— Property Line LL_ h <br /> I LEACHING LIN l0,.Q,a No. & Length of lines d ., Total length/sizeOF / <br /> FILTER BED ❑ Distance to nearest: I li f-Foundation ..— Property Line <br /> ' S it <br /> t <br /> ' SEEPAGE PITS ❑ Depth —� —Size Nu�bei <br /> SUMPS ❑ Distance to nearest: Well _ 'Foundation�.— Property Line <br /> .7 Y <br /> SAL PONDS © O�U <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, and <br /> rules and regulations of the San Joaquin Local Health District. <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 following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compen58- <br /> tion laws of California." <br /> The app' ant must II f r all required inspections. Complete drawing on reverse side. <br /> Signed Title: ©k"' Date: <br /> OR DEPART NT USE ONLY e d <br /> Date �� r� Area <br /> Application Accepted by `� <br /> Pit or Grout Inspection by Date Final Inspection by Date ff <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385., ' f <br /> f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 <br /> � z <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI7'N0. <br /> INFO- <br /> S- <br /> + EH 13-24(RFV.101835 S <br /> EH 14-28 <br /> i <br />