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/ CAPPLICATION FOR PERMIT <br /> N JOAQUIN LOCAL HEALTH DISTRIi <br /> ' 1601 E. HAZELTON AVE., @U14tT <br /> Telephone (209) 6-670gVIRpN��SIC i.TH SERVICES <br /> PERMIT EXPIRES 1 YEAR FROM D TT n THDn7SION <br /> (Complete in Triplicate) L PERMIT <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the <br /> made in compliance with San Joaquin County Ordinance Na.549 for sewage or No. 1 2 for well untp an u nd A alar ons of the Sanascribed. This Joaquin <br /> Local Health District. p <br /> Job Address _S1 DO IF A {{-:J 1 to a 12 Cty t Size <br /> Owner's Name L Y' AddressIrl �613 - <br /> 4�Phon <br /> W'e�T HA /yta i z 33 t; °„`�` C Ar%,,,� <br /> Contract Address l �4 en`se ioovg654q�9 Phone qr6 63577 6 <br /> TYPE OF WELL/PUMP: NE ELL X WELL REPLACE ENT ❑ DESTRUCTION yJ& I <br /> PUMP INSTALLATION SYSTEM RE AIR ❑ OTHER @- /!j'p,,� fvrf we�l5 <br /> D[STANCE TO NEAREST: SEPTIC TANK -2SEWER LINESDISPOSAL FLD. N PROP. LINE n' <br /> FOUNDATION, AGRICULTURE WELL OTHER WELLa PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT ON SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well E cavation i <br /> Dia, of Well Casing i <br /> Domestic rival 19 Gravel Pack ❑ Tracy Type of Casin [�1r <br /> Specifications <br /> ("1 Public C7 Other X Delta Depth of Gro Seal <br /> I I IrrigE <br /> on Type of Grout�2YY` � t� <br /> �'�tpprox, Depth [ 1 Eastern Surface Seal 1 stalled by <br /> « <br /> Repair ork Done ❑ Type of Pump NA H.P. State Work Do e <br /> Wet ruction Well Diameter` Sealing Material (top 50' C <br /> MO+ri Depth - Filler Material (Below 50' <br /> NEW INSTALLATION 17 AEPAIR/ADDITION I 1 DES RUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other _ available within 200 feet-} <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK <br /> ❑ Type/Mfg E <br /> PKG. TREATMENT PLT.,❑ . ,. Dr" en <br /> R;mu i <br /> Distance to nearest: Well _��N�Sr�L�' Z`T ��f1111Kti-"osal ' 1 <br /> 'i�d3H IZ ��S <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundationv1- <br /> Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS 0Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that I have prepared this application and that the work wi iccordance with San Joaquin county ordinances, state laws, and \ <br /> istrict. <br /> rules and regulations of the San Joaquin Local Health D <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 shatl 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 I <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ <br /> tion laws of California." p Y persons subject to workman's compel <br /> applicant must call for all required inspections. Complete drawing op.reverse Side. <br /> Signed XAA& <br /> Title: r eco �G <br /> F EPAR USE ONLV <br /> Application Accepted by Date�-7- <br /> Area 3 <br /> Pit or Grout inspection byDate 9l Final Ins ction by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 885-&385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK 8 <br /> INFO CASH R CEIVED BY DATE PERMIT'N0. <br /> Eh 13-24(REV, <br /> Eli 14.20 9'3 <br />