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11 APPLICATION FOR PERMIT 4.- <br /> SAN <br /> ._SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTONY CA <br /> I' Telephone (209) 466 6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - t (Complete in Triplicate) - <br /> I 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 wail/pump and the Rules and Regulations of the,,San/Joaquin <br /> Local Health District. <br /> -t, <br /> I � City Lot Size PM <br /> Job Address <br /> Address CA L u'• �! r" P one 599 5777'' <br /> Owner's Name <br /> � t°! f p ku <br /> License <br /> Contractor JAddress 25" License No. 02940 f/3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 5:'f SEWER LINES DISPOSAL FLD. �'7/5" PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL — PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS bit <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Y� <br /> f� <br /> Domestic/Private h Gravel Pack ❑ Tracy Type of Casing Pya Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal � Y5 Type ofut <br /> El Irrigation _ Approx. Depth D Eastern Surface Seal Installed by— d4,i)z I n <br /> Repair Work Done Q Type of Pump H.P. 9Ste Work Dona <br /> ell Destruction ❑ W Wilemeter �_ Sealing Material (top 50') ��- <br /> Df� tt/�_ -�0 ' �0 Filler Material IBelow 50'1 <br /> Yp TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo <br /> available within Lith tem emitted if pubo' sewer is <br /> r n , _1 <br /> Installation will serve: Residence_ Commercial_ Other lJ�+ <br /> Number of living units: Number of bedrooms O <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑, Type/Mfg Capacity No. Compartments <br /> '! Method of Disposal <br /> PKG. TREATMENT PLT. ❑:; <br /> 9 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 ❑ Depth Size Number <br /> SUMPS LlDistance to nearest: Well Foundation Y Property tine <br /> i DISPOSAL PONDS � � �❑' – s. - -- �— T <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 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 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." <br /> The applicant ust tail for all requi inspectio S. Complet drawin on everse side. <br /> signed <br /> �J Title' Date: 5 12b <br /> FOR D RTMENT U ONLY <br /> Application Accepted by Date Area <br /> AIIA I` Date�Final Inspection by Date <br /> Pit or Grout Inspection by,; � <br /> Additional Comments: <br /> ❑ Stk .466-6781 ❑ Lodi 369-3621 _ ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> A4MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. ` <br /> INFO <br /> " +EH 1324(REV,1/a 51 <br /> �`: EH 14-26 � �,,- <br />