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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL AVE., STOCICTON, CA W Mr C <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �. (Complete in Triplicate) This {,ca't�n is <br /> � . ndfor install the work herein <br /> Application is hereby made to the San Joaquin ui O d ordinance No.549 for sewage or permit <br /> No. 1862 forcwell/pump and the Rules and Regulations of the san Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. C PM <br /> ��"/ Z � City Lot Size <br /> tc i 1 <br /> Job Address �� <br /> Phone <br /> Address — <br /> Owner's Name <br /> License No.�-- Phone <br /> Address <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FED. POOP. LINE <br /> SEWER LINES --- p{T515UMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK . AGRICULTURE WELL OTHER WELL <br /> FOUNDATION f+ <br /> INTENDED USE TYPE OF WELL Dia. <br /> CONSTRUCTION SPECIFICATIONS <br /> _ EM AREA Dia. of Wel{ Casing `w <br /> �- ❑ Open Bottom*. ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial e Specifications <br /> Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout — <br /> Other ❑ Delta Depth of Grout Seal <br /> ❑ <br /> ('1 Public '� ,' Seal Installed by <br /> I I Irrigation _.Approxi Depth t I Eastern Surface' H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump Sealing Material [top 501 <br /> Well Destruction ❑ Well Diameter -- <br /> e Depth I Filler Material (Below 50'1 <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW iNST ELATION l 1 REPAIfl/ADDITION l i DESTRUCTION Wo septic system permitted if public sewer is <br /> In t llation4will serve: ResidenceCoTt+rttercial Other�� <br /> Number of living units: { Number of bedrooms�, Water table depth <br /> Ghar'acter of soil to a depth of 3 feet: Capacity _6 No. Compartments 2-- <br /> SEPTIC TANK 16 Type/Mfg Method of Disposal <br /> ;PKG. TREATMENT PLT.❑ Foundation Property Line <br /> Distance to nearest: Well <br /> ! ` <br /> E +—` 1 !Totallengthlsize <br /> LEACHING LINE ❑ No. & Length of lines Pro ert Line <br /> 1. Foundation 4 ` p y <br /> FILTER BED ❑ Distance do nearest: Well t <br /> hl 5'',,� Size Number` <br /> SEEPAGE PITS I i Depth Property Line -- <br /> L1 Distance to nearest: Wel{ Foundation p y <br /> { SUMPS <br /> M DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. work for <br /> th <br /> Home owner or licensed men signature as to become subjectoto vlro kman'sllowing: "I rtcompensation 1ify that in the 8wsoof California•"Contract Vr Contractor'shiringor sub-contracting lsignatushalt ore <br /> employ any person in such <br /> certifies the following:-I certify that in the performance of the work for which this permit is issued, I shall employ persons Is <br /> to workman's compensa <br /> tion laws of California.,. <br /> The applicant mus all for all required <br /> inspections. Comp) drawing on reverse side ,r ` <br /> Date: <br /> Title: <br /> Signed K <br /> l R DEPARTMENT USE ONLY j <br /> Date � Area 4� <br /> Application Accepted by4 , Date <br /> Date Final Inspection by <br /> Pit or Grout inspection by ` <br /> 4 ® a <br /> Additional Comments: A16 <br /> ❑ Stk 466-6761 ❑ Lodi -3621 ❑ Manteca a23-7104 C3 Tracy 835-6385 <br /> Applicant Return all copies to: Erivironmentel Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 n;...;.. <br /> CK RECEIVED By DATE PERMIT'ND. <br /> FEE AMOUNT DUE AMOUNT REMITTED CA541 � <br /> INFO <br /> +.EH 13.24(REV.1/8 5) <br /> EH 14-26 - <br />