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,r <br /> APPLICATION FOR PERMIT � TAT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT` PEGS vSD <br /> 1601 E. HAZEL T ON AVE., TOCKTON, CA R <br /> Telephone (209) -6781 �1 <br /> PERMIT EXPIRES 1 YEAR FF OM DATE ISSUED <br /> (Complete in Trig iicate) L�v,ROtyM�ty�r�A�II- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worl�fliv?*u,�ttns <br /> tlnatsi p cation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules andof the San Joaquin <br /> Local Health District. <br /> Job Address SSS��fs���w --lig) ` w /+/ City Lot Size PM <br /> owner's Name L. �r/S'�f L/�CC� t5�'V'Address a'o c%C�tr S�S14- Phone <br /> .S�uik� S'cj C'A. 9SS/.S- � 'J <br /> Contractor(�yer�ia�GwR Tferl� ess - Ail License No. .?y-�V - Phone T" -A G <br /> TYPE OF WELL/PUMP: NEW W LiA WELL REPLACEMENT ❑ DESTRUCTION ❑ / <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER lir <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r <br /> ❑ Industrial ❑ Open Bottom 11 Manteca Dia. of Wel Excavation Z Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack L e® Tracy Type o1 Casing UC Specifications <br /> ['I Public d9Other/*v&v-, 7 n Delta Depth of G out Seal S Ty of Grout - <br /> I I Irrigation n�Appfox. Depth I I Eastern Surface Seat Installed by ZZ r� _ <br /> Repair Work Done 0 Type dl Pump H.P. State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> lnstaltation will e: Residence Commercial O of <br /> Number of Ili <br /> >n - umber of b ams <br /> Character soeet: Water table depth <br /> SEPTIC T Kfg Ca No. Compartments <br /> PKG. T ATMENMethod ofce to ,rest: Well ;�7FoundatibnZPrapert <br /> LEA HIND E L-i No, ength of lines I length/size <br /> FILTER BED 1.3 Di ante to neafe Well undo 'on Property Line <br /> SEEPAGE PITS I I Depth .-Size Number <br /> SUMPS 1.1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS F) <br /> I hereby certify that I have prepared this application and that the work will be doe 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 compensat on 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, l shall employ persons subject to workman's compensa- <br /> lion laws of California." <br /> The applicantmust call for II required inspections. Complete drawing on reverse side. <br /> Signed X //" Jl Title: � lr�( '��� Date: /�� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date FinBl Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 835-6385 <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9x201 <br /> INFO AMOUNT DUE NT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EH 1724(REV.t/1151 <br /> EH 14.26 <br />