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f ' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISI(, C� r <br /> 1607 F. HAZELTON AVE., STOGKTO,IV, GA <br /> Telephone (209) 4W--67$i p 141984 <br /> f' PERMIT EXPIRES 1 Y'AR FROM DATE ISSUED <br /> A{tf l0iti3tl�il •� <br /> {complete in'Fi";�cate) �dE,�LT�' LC1C�� <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 <br /> made in compliance wit San Joaquin Coun Ordinance No.549 for a D �T ')�'�' <br /> Local Health District. ��2o/A, ge or No. 1862 for weli/pump and the Rules and Regulations of the San l�Joaquin <br /> Job Address <br /> City Loi Size <br /> Owner's Name PM , <br /> Address <br /> --1—„/� <br /> Contractor's Name �1y <br /> TYPE OF WELL/PUMP: License No. <br /> NEW WELL ❑ WELL REPLACEMENT Cl <br /> PUMP INSTALLATION � DESTRUt;ii� <br /> � <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR Cl OTHER ❑ <br /> SEWER LINES �� DISPOSAL FLD. <br /> FOUNDATION PROP. LINE <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE _ TYPE OF WELL PROBLEM AREAPITS/SUMPS <br /> ❑ lndustdaf ❑ Open Bottom - ~ <br /> Domestic/Private ❑ Manteca CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation <br /> ❑ Gravel Pack ❑ Tracy Dia, of Wel! Casing <br /> ❑ Public ❑ Other Type of Casing <br /> ,�y- ❑ Delta Depth of Grout Seal Specifications <br /> ❑ Irrigation 10Approx. Depth ❑ Eastern Type of Grout <br /> Repair Work Done ❑ T p .C�, /0 �S}irface Seat Installed by <br /> Type of Pum -150-��_ H.P. Y <br /> Well Destruction ❑ Weil Diameter State Work Done <br /> Depth <br /> Sealing Material {top 50') <br /> Filter Material {Below 50') <br /> TYPE OF SEPTIC WORK; NEW IIVSTAIl. u'v ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is �C <br /> Installation will serve: Residence!-Commercial available within 200 feet.) t ` <br /> Number of livingunits: Other �V <br /> Number of bedrooms Q <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity. No. Compartments <br /> Distance to nearest: WellMethod of Disposal j <br /> Foundation Property Line <br /> LEACHING LINE ElNo. & Length of lines <br /> FILTER BED ❑ Distance to nearest: WellTotal length/size <br /> Foundation PropertyLine�� <br /> SEEPAGE PITS ID Depth size Number <br /> SUMPS Distance to nearest: Well n <br /> ❑ <br /> DISPOSAL-PONDS ❑ In <br /> done in accordance with San <br /> Property Line�� <br /> I hereby certify that I have prepared this application and that the work will bdone Joaq <br /> rules and regulations of the San Joaquin Local Health District. uin county ordinances, stats laws, and <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,l shall employ <br /> tion laws of California." p <br /> p Y persons subject to workman's compensa- <br /> The applicant T4st call for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: <br /> Date: <br /> FOR D PARTMENT USE ONLY <br /> Application Accepted by fit/ / <br /> Date ! gree 0 <br /> Pit or Grout Inspection by <br /> Date Final Inspection by a�r� <br /> Additional Comments: Date � ,c �- <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6388 <br /> Zy <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 <br /> INFO AMOUNT REMITTED RECEIVED BY <br /> CAA <br /> REV,10/eel SH DATE PERMIT`N0. <br /> � + �� <br />