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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZ hone 2091 466 6781TONI CA <br /> � p - <br /> PER UT EXPIRES 1 YEAR FROM DATE ISSUED _ <br /> l (Complete in Triplicate)ot and/or install the work herein described:TH9 <br /> San Joaquin Local Health District for a permit to 9862 for pump and ttTUI he Rules and Regulations of he Sang Joaquin <br /> Application is hereby made to the S Ordinance No.549 for sewage o .' <br /> made in compliance with San Joaquin County <br /> Local Health District. U' Lot Size ` PM <br /> 1 - <br /> Job Address `� f ,-/ +�c, . Phone # <br /> � Address <br /> ` Owner's NamePh <br /> ane �f <br /> - " mow License Na. DESTRUCTION O , <br /> i Contractor's N e WELL REPLACEMENT ❑ <br /> ! OTHER� WELL D 113TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. <br /> SEWER LINES -- THEIR WELL PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK r-- AGRICULTURE WELL <br /> I FOUNDATION TYPE OF WELL _ PROBLEM-AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> INTENDED USE ❑ Manteca Dia. of Well Excavation e.� <br /> ❑ Industrial ❑ Open Bottom t Specifications <br /> ❑ Tracy Type of Casing <br /> D Gravel Pack F : Type of Grout <br /> p <br /> Domestic/Private p Delta Depth of Grout Seal <br /> ❑ Public ❑ Other <br /> _�gpprox. Depth ❑ Eastern Surface Seal Installed by s <br /> ❑ Irrigation .P -- State Work Done t/ <br /> Repair Work Done C] Type of Pump r Sealing Material (top 50'1 4 <br /> Well Destruction [3 Well Diameter . <br /> Depth r- �. Filler Material {Below 50'1 <br /> I <br /> available within 200 feet.) <br /> ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑- REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> installation will serve: Residence— Commercial! Other <br /> i <br /> Number of living units: Number of bedrooms - J Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> No. & Length of lines f Total length/size <br /> LEACHING LINE /� Property Line 5 <br /> FILTER BED ❑ Distance to nearest: Well 16Z)12f— Foundation_. <br /> Depth �✓ Size �3 y Number / <br /> SEEPAGE PITS .S <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 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 /> ubject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become s <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 California." <br /> The applicant mu . all for all re ired' ctions. Complete drawing on reverse side. <br /> rf Date: <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY <br /> Date '� Area <br /> Application Accepted by <br /> PitCGrou!),'spection b �/� <br /> J Date Zy Final Inspection by Date <br /> }r- <br /> Additional Comments: VJ <br /> ❑ Stk 466"6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-63% <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GK 9 CASH RECEIVED BY DATE PERMIT NO. <br /> INFO �f <br /> +EH 13-24 1REV,10/83) <br /> EH 14-28 <br />