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­__— <br /> APPLICATION FOR PERMIT ' <br /> ' a "P4 F.. <br /> SAN JOAQU1N LOCAL HEALTH DISTRICT <br /> j <br /> s 1601 E. HAZE T ON AVE., ClC TON, CA �� y9 t#� <br /> .'Telephone 12091 <br /> PERMIT EXPIRES"1 YEAR FROM DATE'ISSUED`°nOty� ' ` r <br /> (Complete in Trjplicate} i rig <br /> .. . ,..: <br /> +canon is <br /> APP• n OF <br /> No.549 for sewage or No. 1862 for welilpump and the Rules and flegulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and/or install the work herein,described.This apP <br /> Joaquin County <br /> made in compliance with San Joaq ,. " .� -• <br /> Local Health Districts <br /> r, QPM <br /> Job Addresse <br /> •�L <br /> Address a& -. <br /> }a, <br /> .. a.:.�.� "- -Phone - <br /> �! <br /> Owner's Name <br /> r 3 � i3u�CI <br /> L7" License Na.L � Phone <br /> ress DESTRUCTION ❑ <br /> Contractor <br /> NEW WELL ❑ WELL'REPLACEMENT ❑ r <br /> TYPE OF WELLIPUMP: 3/ OTHER <br /> SYSTEM REPAIR <br /> PUMP INSTALLATION ❑ pROP. LINE <br /> DISPOSAL FLD. <br />' SEWER LINES OTHER <br /> i DISTANCE TO NEAREST: SEPTIC TANK WELL <br /> FOUNDATION AGRICULTURE WELL PITS/SUMPS <br /> f <br /> WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE TYPE OF <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> rial Type of Casing Specifications <br /> t <br /> 9?,5 <br /> ,l <br /> 0 ln� ❑ Gravel Pack ❑ Tracy Type of Grout <br /> omesticlPrivate ❑_Delta Depth of Grout Seal <br /> ❑ Public ❑ Other <br /> Surface Seal Installed by �. <br /> El Irrigation ---Approx. Depth ❑ F,astern, State Work Done <br /> Type of Pump �"`:f•� <br /> Repair Work Done N.P._ Sealing Material(top 50') <br /> well Destruction Elwell Diameter �� <br /> Depth l Filler Material (Below 50'1 <br /> available within 200 feet.) a� <br /> TYPE OF SEPTIC WORK: N11 EW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer +s <br /> l .. .%W <br /> Installation will serve: Residence, Commercial Other <br /> _.,,...Number of living units: <br /> Number of bedrooms Water table depth +'m <br /> I —Character of soil to a depth of 3 feet: No. Compartments <br /> /Mfg T Capacity_ � <br /> SE ❑ Type <br /> /Mfg TANK _. . -Methed-of Dlspo'sa1 <br /> PKG:TREATMENT PL-T7❑" -"''—� i PropertQLine <br /> Distance to nearest: Well ' -Foundation��I <br /> 7 }" f Total length/size' <br /> LEACHING LINE ❑ No. & Length of linesr�"' , Property Line <br /> Foundation:�+1 <br /> FILTER BED ❑ Distance to nearest: Well r <br /> .� Number <br /> I SEEPAGE PITS "El Depth <br /> Size ' Property Line <br /> MPS <br /> f Foundation. <br /> SU ❑ Distarice to nearest: Well o + <br /> ';.. <br /> DISPOSAL PONDS ❑ �» <br /> ! here certify that I�have prepared this application and that the work will be done in'accordance with $a�Joaquin count��rdinances, state laws, and r <br /> rules and regulations of the San Joaquin Local Health following: <br /> rmit is issued, fshall not Lr <br /> Home owner or licen gents nature certifies the foliowin l certify that in the per€ormance of the Co kractor's hirin s.pe signature <br /> employ any perso such manner s to bee rformancect to eovkoma o orrlp Lhis pe m t is issu dif�shall employape�sons+subject t wo�kman'Iscompensa <br /> ` certifies the folio ng:"I certify th in pe <br /> I 01 <br /> tion laws of C +forma." drawin on revs e• <br /> re ired in til t 4 The appiica must K�Ave- 'Oe'-Dbate <br /> i e: <br /> : <br /> 7 Q. _ <br /> g Signed <br /> k + FOR DEPARTMENT USE ONLY <br /> 7 <br /> Date" Area <br /> Application Accepted-by <br /> Date.t.__ <br /> I '" Final Inspection by <br /> Date <br /> f Pit or Grout Inspection by <br /> Additional Comments: 'r4 ❑ Tracy 835- <br /> j�Stk 466 6781 ❑ Lodi 369-3621 ❑ Ma eco %1104 Stk.-CA 95201 <br /> /Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltori Ave., P.O. Box 2009, <br /> -� <br /> !_ CK PATE PERMIT"NO. <br /> AMOUNT REMITTED CASH RECEIVED 8Y _ <br /> FEE AMOUNT DUE <br /> � <br /> INFO <br /> +E41 1324(RFV.t/a 51 - .. - - _••. <br /> EH 14-26 .. y 1_. •- <br />