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1 <br /> APPLICATION FOR PERMIT-i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F 1601 E. HAZE i ON AVE., ST.00KTON, CA <br /> Telephone (209) 466-6781 <br /> r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED roti <br /> l (Complete in-Triplicate) - . ,,A rl° <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District., <br /> Job Address �b a CityJ Lot Size - PM <br /> n,QJ12- <br /> Owners Name _,�� - �r5r Address 132 Phone <br /> Contractor- S• Address �^ 46"`J rcense N a Phone _ � <br /> ' TYPE OF WELL/PUMP: if NEW W ELL,7K WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N s <br /> ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private GravelPack i Tracy Type of Casing Specifications <br /> C1 Public F-1 Other I - 10 <br /> f ❑ Delta Depth of Grout Seal J Type of Grout G` <br /> ❑ Irrigation L—Approx. Depth ❑ Eastern Surface Seal Installed �} <br /> r p� 7 � <br /> Repair Work Done ❑ Type of.Pump H.P. State Work Don <br /> Well Destruction C1 Well Diameter Sealing Material (top 501 0 <br /> Depth ` Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> r available-within 200 feet.) <br /> Installation will serve: Residence-_ Commercial, Other <br /> Nunitler-of living units: f Number of bedrooms <br /> Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC TANK ❑ I Type/Mfg Capacity No. Compartments -� <br /> PKG TREATMENT PLT. ❑ s Method of Disposal <br /> U <br /> Distance to-nearest: Well Foundation Property Line r <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> s <br /> FILTER BED ❑ Distance to nearest: Well Foundation t. Property Line <br /> ' 1 4 <br /> SEEPAGE PITS ❑,''Depth Size Number e. <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> ~DISPOSAL:PONDS ❑ ': s <br /> hereby certify that I have prepared thig,application and that the work will be done in accordance with San Joaquin 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 work for which this permit is issued, I shall 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 <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion taws of C ifornia." <br /> The applica t ust call for all requ' inspections. Complete drawin 4reveside. <br /> Signed x S <br /> it Date: / 41-Y6 ' <br /> r ,t <br /> FOR OE RTMEIYT USE ONL <br /> Application Accepted by ! " ' r Date Area <br /> Pit or Grout Inspection by Date Final Inspection by �~ Date <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7-104.'x'%' "UTracy 835-W% <br /> Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> FEE <br /> EH 14 <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> + EH W241REV.(/951 � �1 C ./ ���� �67 , <br /> 28 k? ^` a La - <br /> } <br />