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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ 1601 E. NAZELi ON AVE., STOCK70N, CA <br /> i Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED R <br /> { (Complete in Triplicate) pbl <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Addres 6 �12City Lot Size PM <br /> Iva• <br /> Owner's Name ,1 �. Address _/� lLf `�Q,/�� <br /> — Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE ` <br /> -"FOUNDATION RICULTURE WE�UCTION <br /> OTHER WELL PITS/SUMPS ; <br /> INTENDED USE t /TYPE OF WELL PROBLEM A A CONS SPECIFICATIONS <br /> ❑ lndustrial a❑ Open Bottom ❑ Manteca Di of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑,Gravel Pack ❑ Tracy pe of Casing Specifications <br /> F1 Public C7 Other + Ll Delta De of Grout Seal Type of Grout <br /> i I Irrigation ;w-Approx, Depth I I Eastern Surfac Seal Installed by <br /> Repair Work Done ❑ 7ype of Pump P. State Work pone <br /> Well Destruction ❑ i\ell Diameter ti Sealing Material (top 501 <br /> f Depth + I Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK:" NEW INSTALLATION I:] REPAIR/ADOITION I I DESTRUCTION (No septic system permitted if public sewer is-- <br /> et- <br /> "7 <br /> sm- = <br /> available within 200 feet.) <br /> = Installation will serve Res'd nce� Commercial— Other <br /> Number of living units: Number of bedrooms.- f z. <br /> Character of soil to a de hsof 3 feet: Water table depth <br /> SEPTIC TANK "Type/Mfg'-' �- Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 + <br /> _ Method of Disposal � <br /> Distance to nearest: Well `rt Foundation Property.Line <br /> { � 3 <br /> LEACHING LINE ❑ No.-&' Length of lines ` _Total length/siie <br /> FILTER BED ❑ Distance to nearest: Well FoundationProperty Line <br /> } r' . <br /> SEEPAGE PITS i I .Depth I Size Nb = <br /> r - .:,,. Number <br /> SUMPS Cl 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. f <br /> rules and regulations of the San Joaquini Local Health District. y <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,shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring.or sub-contracting signature h <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-r, <br /> tion laws of Califor ' , I , I i <br /> .tr <br /> The applicant c for all aqui ei ns. Complete drawing on reverse side. ~' <br /> XSigned X i Title: pate: " v <br /> g FORD AFIT dENT USE ONLY <br /> Application Accepted by" Date <br /> x ea <br /> Pit or Grout inspection by D Final Inspection by bate <br /> Additional Comments: r' —3 <br /> r <br /> ❑.Stk 466-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7184 ❑ Tracy 635-6385 � .i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95281 <br /> FEE h INFO AMOUNT DUE AMOUNT REMITTED CK CA H RECEIVED 8Y DATE PERMrT'NO. <br /> +.EH 1 <br /> 3-44(REV.rifts) f3s <br /> EH 14-28 £ ',?3 / ,�7"_fr 7�CQ '6♦ d <br />