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*' APPLICATION FOR PERMIT <br /> •' r <br /> SAAR JOA.(IUIN LOCAL HEALTH DISTRICT V <br /> HAZE,—I ON AVE., STOCKTONCA, <br /> 1601 E. I-I JA Iv <br /> Telephone (209) 466-6781 SAy. k r <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED AL 'QUIN Lo <br /> (Complete in Triplicate) rgrppl <br /> �r �A <br /> cation is <br /> Application is hereby made to the San Joaquin Local Health District for <br /> a e or it to 1862 construct <br /> for and <br /> Ior i and the Rule and ll the work herein <br /> desctions of San'Joaquin <br /> made in compliance with San Joaquin County Ordinance No;549 o g <br /> Local Health District. .• �' " <br /> Lot Siz� PIM . <br /> Job Address SMfTh t' City , <br /> Phone <br /> Owner's Name �jf� <br /> Phone'� y R 5 I ,a 1'Z. �, i v �' b <br /> lie �' 630 <br /> i Contractor's Name rt4 f License No. <br /> TYPE OF WELL/PUMP.: `i� ��. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> t PUMP INSTALLATION ❑ SYSTEM-REPAIR C3OTHER El <br /> SEWER LINES DISPOSAL FLD. PROP. LINE s. <br /> .DISTANCE TO NEAREST: SEPTIC.TAN_K.. pITSISUMPS <br /> 3'FOUNDATION AGRICULTURE WELL OTHER WELL <br /> t --1 INTENDED USE , TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [I kndustdll ED Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 1 Dia. of Well Casing ' <br /> Type of Casing--- Specifications <br /> ? .D Domestic/Private 0 Gravel Pack '❑•Tracy yp <br /> p Delta Depth of Grout Seal __ Type of Grout # <br /> ❑ Public ❑ Other <br /> F ---Approx. Depth Q Eastern Surface Seal Installed by <br /> ❑ Irrigation <br /> State Work Done <br /> ''Repair Work Done L1 Type of Pump <br /> H.P. <br /> r Well Destruction Q Well Diameter Sealing Materia! (top 50'1 <br /> l Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 11 (No <br /> septiailablec systemthin rmitted,if public.sewer is �r <br />' I Installation will serve: Rest ante X Commercial— Other / <br /> R ,Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> 'SEPTIC TANK ElType/Mfg I� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well�-."� Foundation Property Line <br /> LEACHING LINE '�„I No. & Length of lines Total lengthisize <br /> t; Property Line <br /> I FILTER BED ❑ Distance to nearest: Well Foundation <br /> I <br /> R I Size Ymber j <br /> SEEPAGE PITS ❑ Depth Property Line l b <br /> SUMPS . Distance to nearest:' Well Foundation ' <br /> •DISPOSAL PONDS ❑ 4 <br /> ! hereby certify that! have prepared this application and that j6e'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, l shall not <br /> ' employ any-person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following "1 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__' 'Ior r. �"n <br /> ► <br /> � s. <br /> ThWappkicant tnu c for.all r uireClY s ctions. Complete drawing .reverse s' <br /> Date:11 <br /> Title <br /> s� { ' 1 FOR DEPARTMENT USE ONLY <br /> 1!tt{r it 3s r �� Date / Area <br /> r:� Application Accepted by <br /> F " T Final Inspection b.yDate I r•+- Date <br /> +f Pit or GroutInspection by - <br /> i <br /> V <br /> E "Additional Comments: Yr' StkY � <br /> LS tk 466-6781 1 ❑ Lodi 369-3621 El Manteca 823-71040 ❑ Tracy 635-6385 + I <br /> Applicant- ReZurn all copies to: Environmental Health Permit/Services 1601E. Hazelton"Ave.. P.O."Box 2009,- CA95201 <br /> - CK <br /> •FEE� CASH -;�' •RECEIVED t3Y"'� PERMIT'NC1.'... .-•.-.•� <br /> f - AMOUNT DUE_„.� AMOUNT REMITTED <br /> INFO r r t <br /> + Eli 13-24IREV.101831 <br /> EH 14.26 <br />