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' PERMIT <br /> I APPLICATION FOR � . <br /> t 4 SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> ` - <br /> 1601 E. HAZEL70N AVE., 570CKTON, CA Y Z_ <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> C (Complete in Triplicate) <br /> F 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 /> City J Lot Size �S X ® PM <br /> Job Address / <br /> A �- Address Phone <br /> Olv Z� <br /> wner's Name c <br /> Contractor •� a Address License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications <br /> (-1Public i=1 Other F1 Delta Depth of Grout Sea! Type of Grout _ <br /> 1 Irrigation _-Approx: Depth 4 I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ' Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1.) DESTRUCTION rT (No septic system permitted if public sewer is <br /> available within 200 feet.] , ,1 <br /> Installation will serve: Residence— Commercial_ Other 1�+ <br /> Number of living units: Number of bedrooms 6 <br /> ! Character of soil to a depth of 3 feet: Water table depth 0C <br /> SEPTIC TANK ❑: Type/Mfg e on- d= Capacity (1 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line (� <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> J <br /> SUMPS ❑ 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 <br /> rules and regulations of the San Joaquin Local Health Di1trict. <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, 1 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." w <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> " Application.Accepted by �• Date 7 IQ j� Area <br /> Pit or Grout Inspection by1� )bate Final Inspection by Date x <br /> Additional Comments: '�'�- � a [ + 5—/- <br /> 0 <br /> /—❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-&385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 1 <br /> 3-24(REV.1ih51 { Sem""` 3EH 14-28 1428 J <br />