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r kx <br /> E <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH_pIST,RICT <br /> 1601 E. HAZE T ON AVE., I TOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r <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/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. fl"� [ .P �-[,. J¢Cl�.-. 22g 012c) .-QS' <br /> l <br /> Job Address / City Lot Size PM <br /> Owner's Name ' 4'I'F Address � - Phone <br /> Contractor Sa"U'. —, Address ` 4 License No. :5 12?C-9 2 Phone 4169—167(2- <br /> TYPE <br /> $7 -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER �- J►`l�ltl Vr�l WnLd,�J � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEJ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> it <br /> ❑ Industrial . © Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public Other F1 Delta Depth of Grout Seal Type,of Grout <br /> I I Irrigation Approx Depth I.) Eastern Surface Seal Installed b-_y....-_. zt�'a�ys4_ r1 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 54') <br /> "} <br /> Depth t Filler Material (Below 50') I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is m <br /> available within 200 feet.) <br /> Installationlrwl erne: Residence � Commercial— Other <br /> Number of living units: Number of be, <br /> Character of soil to a depth of 3 feet-. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments P <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ] <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total'length/sEz <br /> I <br /> FILTER BED ❑ Distance to nearest: Well, Foundation PropertyLine <br /> I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LD 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 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, I shall employ persons subject to workman's compensa- <br /> tion laws of a ornia." i x <br /> The app)' ant ust calf for II re fired in c ns Complete drawing on reverse side. <br /> Signed Title: / � �- Date: <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by -�/ Date Area <br /> ' V/U Fr <br /> Pit or Grout Inspection by Fi I Inspection by Date <br /> 11 Additional Comments: / <br /> ❑ Stk 466-6781 ❑ i 369-36#1 ❑ Manteca 823-7104 Tracy 835.6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 5201 <br /> FEE <br /> INFO AMOUNT DUE ` AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> +.EH 1324 IREV.1/x 51 <br /> EH 1426 <br /> 1 <br />