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A71 <br /> Y ` 'L <br /> APPLICATION FOR PERMIT <br /> LTH DISTRICT <br /> jtb <br /> SAN JOAQUIN LOCAL HEA :,. <br /> 1601 E. HAZE- ON AVE., STOCICTON, CA <br /> .1 r. <br /> Telephone 12091 466-6781 - <br /> 1 YEAR FROM DATE ISSUED <br /> PERMIT EXPIRES ENViFtUINT HEALTH <br /> (Complete in Triplicate) FF(�(,J�tT �1= V application is <br /> to for welllpump and the Rules and Regulations of the San Joaquin <br /> ,eb made to the San Joaquin Local Health <br /> District <br /> sewage or INa tgg2truct and/or install the work ere,n escn e <br /> Application is he Y Joaquin County Ordinance <br /> made in compliance with San <br /> Local Health District. Lot Size PM�—— <br /> City .�. <br /> Job Addresi / 1 4 Phone <br /> 7j'�� s <br /> Owner's Name" n � / (o �3 7� <br /> 4 License No Phonk 1—� <br /> Address DESTRUCTION ❑ <br /> Contractor L NEW WELL ❑ WELL REPLACEMENT ❑ OTHER ❑ <br /> TYPE ELLIPUMP: SYSTEM REPAIR 21 PROP. LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLD._�� <br /> SEWER LINES PITS/SUMPS <br /> �� OTNER'WELL_ — <br /> DISTANCE TO NEAREST: SEPTIC TANK --� AGRICULTURE WELL <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL <br /> PROBL�BLEAREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Manteca Dia. of Well Excavation Specifications <br /> [I Industrial ❑ Open Bottom❑ GraveType of Casing <br /> Gravel Pack ❑ Tracy Type of Grout --�--- <br /> 0 DomesticlPrivate 17 Delta Depth o1 Grout Seal _ <br /> M Other $ ca Seal Installed by <br /> i Public <br /> �Ci Irrigation �APprox. Depth I i Eastern State Work Done �f <br /> Type of Pump L14L_`� H.P. <br /> Repair Work Done ❑ TYp Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter — Filler Material IBelow 50`) <br /> Depth Permined if public sewer is <br /> available within 200 feet., <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITIDN i I DESTRUCTION I 1 (No septic system <br /> - -1 ial� Other 1---- <br /> Installation will serve: Residence Commerc <br /> Number of living units: <br /> Number of bedrooms W er table depth <br /> Character of soil to a depth of 3 feet: No�Compartments <br /> Capacity-------: Y I <br /> SEPTIC TANK ❑ Type/Mfg Meihod of Disposal <br /> PKG. TREATMENT PLT.❑ Foundation_ � Property Mine <br /> Distance to nearest: Well �— I <br /> Total lengthlsize <br /> LEACHING LINE ❑ No. & Length of lines property ine -- <br /> FILTER SED Ll Distance to nearest: Wel! <br /> Foundation <br /> SEEPAGE PITS I i Depth Size Number <br /> L-1 Distance to nearest: Well Foundation Property ine <br /> SUMPS _ r r <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San J aquin 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 Corti for which this permit is issued, I signature <br /> she not <br /> s of California <br /> employ any person in such manner <br /> fnthat n the performance of the work afor whichehispe maws issued, I shall emoloyi Personsrsubj sring ubject t workmanlscompensa- <br /> certifies the following: " Y <br /> P p <br /> tion laws of California." <br /> The appli7C:2rg�;= <br /> win/g own,reverse side. <br /> Signed X <br /> itl -'� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date V G J Area <br /> Application Accepte/by:�_­-- by Date <br /> / <br /> Pit or Grout InspectDate <br /> Final Inspection <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 <br /> FEECK# RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-211REV.rin51 <br /> EH 14-2e <br />