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<br /> I t:onusctor'a Name Lk�rms No
<br /> PE OF WELL/PUMP t = 1�IEW WELL,f WELL R I.ACEMENT ❑ DESTRUCTION
<br /> pt1M�+#• V7ALLAON3 x S1f&TEMfREPAIR ❑ OTHER ❑
<br /> .DISTANCE TO NEAREST. 'TA14K :.y:=:;:._,;SIMEIfi'LINES >' _ DISPOSAL FLD. PROP.1lNE _...
<br /> OUNOATION ,:,; AGRICULTURE WELL' ._ OTHER WELL PITS/SUMPS,
<br /> INTENDED of° K kTYPE OF WELT. PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r
<br /> Ir►duurkd # Bgttam°` Maltloa4a Die.of Wel Excavation ms. of Woo Caft
<br /> v
<br /> Privets ` ,. Padt1 Tracy Type Casing Specifications
<br /> r of
<br /> bthsri f Delta Depth of Grout Seal Type of Grout
<br /> #frligatlon ' �Qlt' Surface Seal Installed by
<br /> d n a
<br /> Rapak Work Done C�r of H R .' State Work Dome �•
<br /> W4E Destruction L7 Wr0 Diarnatet y " Sealing Material(top 50'i °
<br /> Depth
<br /> Filler Material(Below 50') '�
<br /> TYPE.LIF SEPTIC WORF4 =NEW.MISTALLA ION LJ REPAIRIADD111ONO, DESTRUCTION ❑ (No septic system permitted if pubic ssum fs
<br /> ,. available within 200 feet.)
<br /> Installation will server Residence.. Commercial, _ Other
<br /> Number of living units: Number of bedrooms
<br /> Chwacter of sol to a depth,of 3 feet: Water table depth
<br /> SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments .
<br /> PKG. TREATMENT PLT.❑ Method of Disposal
<br /> Distance to nearest: Well Foundation Property Line
<br /> LEACHING LINE: O No B Length of Orm Total length/ai a
<br /> FILTER BED ' ❑ Distance to nearest: _Well Foundation Property Line
<br /> SEEPAGE PITS O Depth Size Number
<br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line
<br /> DISPOSAL PONDS ❑
<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 andulations of the San Joaquin oaquin Local Health District. i
<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, 1 shall not 1
<br /> employ any p"n in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature
<br /> certifies the fai(owing:"I that in the rformence of the work for which this permit is issued,I shall employ persons subject to workman's compensa-
<br /> tion laws of lifomia."
<br /> The applic calf fo fired ns. omplete drawing on reverse side.
<br /> Signed ` Title: Date:
<br /> 1
<br /> FOR DEPARTMENT USE ONLY
<br /> Application Accepted by �A �,r& Date r Area
<br /> Pit or Grout Inspection by Date inal Inspection by M 1 ' Data ✓
<br /> Additional Comments: '
<br /> ❑ Stk 466-6781 ❑ Lodi 389-3621 Man 71 ❑ TVA cy 835-6'385
<br /> Applicant- Return all copies to: Environmental Health Perrnit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 86201
<br /> PEO AMOUNT DDUUE, AMOUNT REMITTED CASH RECEIVED BY DATE PERmrr NO. t
<br /> H1 13.241REV.:10/031 i'r ` O
<br /> IN 14-20
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