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APPLICATION FOR PERMIT r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTS <br /> 1601 E. HAZEL I ON AVE., STOC 1TON, CA C` � ► <br /> Telephone (209) 466 678 )1 l�} ' /,98,9 <br /> D <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I� <br /> (Complete in Triplicate) N�IR�Nf his application is E <br /> install the pin ,� an Joaquin <br /> Application is hereby made to theFSan Joaquin Local Health Dig foot sewapermit <br /> e o rNo. 1862 for well pump and the Ru to construct and/or es and Re VI r E� <br /> made in compliance with San Joagwn County Ordinance .� �"�� <br /> Local Health District. 11 �� �0(,� <br /> f Y� a lty� Lot Size PM <br /> (r2 U il' '' <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Name /)/)� <br /> erase No.S✓YC��Phone l 3� <br /> Address <br /> Gontractor DESTRUCTION ❑ ?3b <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ , <br /> PUMP INSTALLATION ❑ PROP. LINE <br /> SEWER LINES � DISPOSAL FLD.�� <br /> DISTANCE TO NEAREST: SEPTIC TANK rap PITS/SUMPS 1 <br /> FOUI NDATION <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPF OF WELL <br /> PROBLEM CONSTRUCTION SPECIFICATIONS <br /> � EM ADia. of Well Casing <br /> ❑ ripen Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial p Type of Casing Specifications <br /> Gravel Pack X Tracy <br /> Domestic/Private Type of Grout <br /> ❑ ether n.Delta Depth of Grout Seat _ - <br /> r Public {�J �„ Surface Seal installed by <br /> - <br /> Repair <br /> 1 irrigation ` ( 0--ij.-Approx. Depth t I Eastern State Work Dane <br /> Repair Work Done ❑ Typ of Pump H.P. <br /> Sealing Material Itop 51 y <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION 1 l available rwthin 200 feet.) <br /> ed if public sewer is <br /> Other .-- " .•s <br /> Installation_will sere:; Res' encs— Commercial _ _ <br /> Number of living units: ! Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> Capacity <br /> SEPTIC TANK ❑ ,Type/Mfg Method of Disposal <br /> I <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> i Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE ❑ I INo. & Length of lines Property Line <br /> FILTER BED <br /> ❑ :Distance to nearest: Well Foundation P y <br /> SEEPAGE PITS I I i Depth <br /> Size Number <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> I, <br /> rules and regulations of theli an Joaquin local Health District. ify that in the g work for <br /> Home owner or licensed <br /> n such ee signature <br /> gas to become suhe f oleo wrorkman'srtcompensation Iw soof Califo�niahe Contractar'srhu hiring or sub-contracting l signature <br /> l <br /> employ any person pe p persons subject to workman's compensa <br /> certifies the following:"I certifythat in the rformance of the work for which this permit is issued, I shall employ <br /> tion laws of California." <br /> The appli nt ust call fol ll requir inspections. omplete drawing orf reverse side. <br /> r U Date: <br /> tle: <br /> Ti <br /> Signed X I <br /> R DEPARTMENT USE ONLY �l <br /> r I Date 5 7 Area <br /> Application Accepted by !� <br /> 1� Date Final Inspection by Date <br /> Pit or Grout Inspection byl� <br /> Additional Comments: <br /> I <br /> -6385 <br /> ❑ Still 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 <br /> Applicant - Return•rill copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 <br /> FEE AIMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> ATE <br /> PERMIT ND. i <br /> INFO ' p.{� <br /> { ✓/j/./J� . , <br /> ♦ EH 13-24(REV.I R5) <br /> EH 14-26 <br />