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APPLiCATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH <br /> 1601 E. HAZE T ON AVE. DISTRICT � <br /> Telephone'(209) 466 6781 TON, CA <br /> I <br /> PERMIT EXPlRES'1 YEAR FROM DATE ISSUED <br /> Application is hereby made to the San Joaquin Local Health District M Prete Tripllcate) <br /> made Health <br /> with San Joaquin County Ordinance No. Permit to construct and/or install the work herein des <br /> l Local Health District. 549 for sewage or t construct <br /> r well/ urn }` <br /> g P p and the Rules and Regulations of he San Joaquin <br /> application is <br /> Job Address ty <br /> .. r. lty � <br /> Owner's Name CLot Size ��/�M <br /> r Address_ � � <br /> Contractor Phone 9 <br /> TYPE OF WELL/PUMP: Address D <br /> NEW WELL ❑ LL REPLACEMENT ❑ License No. <br /> WE <br /> PUMP INSTALLATION L3 ��a �L Phone <br /> DISTANCE TO NEAREST: SEPTIC TANKxDESTRLICTION ❑ <br /> 5Y5TEM REPAIR ❑ <br /> ---7— SEWER LINES OTHER ❑ <br /> FOUNDATION ------ DISPOSAL FLD. <br /> INTENDED USE AGRICULTURE WELL PROP. LINE <br /> TYPE OF WELL -, � —� OTHER WELL <br /> 11 TYPE PROBLEM AREA PiTS/SUMPS <br /> ❑ Open Bottom 4 �ONSTRUCTiON SPECIFICATIONS <br /> l y <br /> ❑ Domestic/Private =Manteca. <br /> ❑ Gravel Pack Dia, of Well Excavation ` <br /> ❑ Public 12 Other ❑ Tracy Type of Casing , Dta, of Well Casing <br /> IJ Irrigation £ ❑ Delta Depth of Grout Seal Specifications <br /> ----Approx. Depth ' <br /> Repair Work Done Type of Pump ❑ Eastern Surface Seal installed by 'Type of Grout <br /> Well Destruction ❑ �� P <br /> Well Diameter State Work Done <br /> Sealing Material (tap 50') ^ <br /> Depth �- y Filter Material-(Bei_ow.50,)* ^" + <br /> TYPE OF SEPTIC WORK: JillEW INSTALLATION ❑ REPAIRlgDD1TlON ❑ DESTRUCTION <br /> (No septic system permitted if public sewer is <br /> Installation will serve: Residence <br /> CommerYal Other�� vai <br /> Number of living labile within 200 feet.) <br /> units: •" <br /> Character of soil to a depth of 3 feet: of bedrooms <br /> r �. <br /> SEPTIC TANK <br /> PKG. TREATMENT PLT. E] Capacity <br /> Water table depth <br /> Capacity No. compartments <br /> Distance to nearest: WellMethod of Disposal <br /> LEACHING LINE . <br /> Foundation� property Line /r <br /> ❑ No. & Length"of lines <br /> FiLTER BED ❑ .Distance to nearest. Total length/size <br /> Weil Foundation M1 <br /> Property Line <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS Size <br /> ❑ Distance to nearest: Well Number <br /> DiSP05AL PONDS ❑ Foundation property Line <br /> I hereby certify that! have prepared this application and that the work will be done in accordance with San Joaquin <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: Paquin county ordinances, state laws, and <br /> employ any person in such manner as to become subject to workman's compensation laws of California.,,Contractor's hiring or sub-contracting <br /> in the Performance of the work for which this permit is issued, l shall not <br /> certifies the following: '9 certify that in the performance of the work for which this permit is issued, i shall employ tion laws of California." <br /> p 9 signature <br /> A y persons subject to workman's compensa- <br /> The applicant must cal it re d inspe ns. Complete drawing,on�reverse.,side. <br /> PSigned X 'k-will- ..'Willi '4 <br /> !� Title: <br /> Date: <br /> ��- FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Pit or Grout Inspection by - r_. Date Area <br /> M - Date Final Inspection by , <br /> Additional Commen -+ Date <br /> ❑ Sik 466-6781 ❑ odi 369 3621 <br /> ❑ Manteca 823-7104 Q Tracy 835.6385 <br /> Applicant- Return ali copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> .� <br /> FEE AMOUNT DUE y <br /> INFO AMOUNT-REMITTED CASH I RECEIVED BY <br /> DATE PERMiY NO. <br /> EH 13-24(REV.I/e et -- �• -. � <br />.H 14-28 C? o <br />