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APPLICATION FOR PERMIT y6 b 1 <br /> SAN JOAQUIN LOCAL HEALTH Jj <br /> 1601 E. H�AZETOIV,AVE., STOCK CA <br /> Telephone (209) 466-6781 I <br /> PERMIT EXPIRES TYEAR FROM DATEJMlf,9. 1980 <br /> , <br /> (Complete in Triplicate) <br /> Application is hereb o Joaquin Local Health District for a permit to construe+� N9" v }Oklrein described. This application is <br /> made in E, County Ordinance No.549 for sewage or No. 1862 for weR, TJ&PR +LM"and Regulations of the San Joaquin <br /> Local Health ii4�r 0 <br /> S <br /> Job Address �C/" � City I-eu ize PM <br /> Owner' ameCddress Phone 0 <br /> Contractor AddressIq License No. f 73 Phone_ 29- r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ } <br /> 1 <br /> PUMP INSTALLATION a� SYSTEM REPAIR ❑ OTHER ❑ <br /> s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM A'REQ —;CQNSTRUCTIOIV SPECIFICATIONS <br /> C] Industrial,._._ ._ ❑ Open�Bottom— [;]-Manteca+ - •Dia--oi Well_Ezcavation..---- - -..._. —Dia.,of Well Casing <br /> [domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta f___----'Depth of'Grout Seal Type of Grout <br /> i I Irrigation - - .Approx. Depth I I E tern �".- S rface Seal Installed by _ <br /> Repair Work Dane C7 Type of Pump H.P? % State Work Done <br /> Well Destruction LJ Well Diameter Sealing Material (top i v <br /> Depth Filler Material I13eloy,;50. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITIONL�l I `DESTRUCTION [ I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r Installation will serve: Residence.. Co 'c <br /> ___-_ Other <br /> NN <br /> Number of living units:, F umber.off drooms <br /> L—Character-of-soR-to.a-depth of., iLeet:J Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines # ''Notal length/size <br /> FILTER BED ❑ Distance to neatest: Well Foundation # f. Property Line <br /> � � 1 <br /> SEEPAGE PITS 11 Depth Size ,Number <br /> t <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ! Li <br /> I hereby certify that I have prepared this application and that the work will be done in:accurdance with San Joaquin county ordinances, state laws, and <br /> rules and0,,,, <br /> San Joaquin Local Health Ditrict. <br /> Home awed age 's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ asuch man or as to bec a subj to workman's compensation lawsof California." Contractor's hiring or sub-contracting signature <br /> certifies t "I certi that in the or e f the work for which this permit is"issued, I shall employ persons subject to workman's compensa- <br /> tion laws .'The applill f a!I req e o Co ete drawing on <br /> Signed X Title: <br /> t <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted byDate r� U Area <br /> a <br /> Pit or Grout Inspection by Date Final Inspection by Date U <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ 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 /> CK 40 F i <br /> FEE AMOUNT DUE AMOUNT REMITTED INFOCA5H RECEIVED BY DATE PERMIT-NO. <br /> + EH13.24 I REV. <br /> EH 14-26 S �/1 I/ 1 O <br />