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• <br /> APPLICATION FOR PERMIT y3- 1/)(� <br /> 7 <br /> u <br /> /) SAN E. HA P LOCAL HEALTH uiTO'N,C <br /> 1601 E. HAZELTON AVE., STUCKTON, CA PERPIIT N0. <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. Th' p c�ion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rulesllftions of the S�a�nt Joaquin Local Health District, <br /> Job Address �,.�� _ "`�.� /�/ S% Subdivision Name ,� r� <br /> Owner's Name <br /> Address a2 k24 �//L! [2� 5�— Phone <br /> Contractor's Name <br /> /'Lf R Y/I5 Wir1T i e-n e No. "3 ��� Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL �i WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ( SYSTEM REPAIR OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK 3D D A` SEWER LINES J-0-IP 4-- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION *74S `_ <br /> AGRICULTURE WELL Z O Q fi OTHER WELL PITS/SUMPSQ �- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATLONS <br /> J Industrial U Open Bottom Manteca Dia. of Well Excavation /��/( <br /> Domestic/Private Wravel Pack F_�Tracy Dia. of Well Casing //�� <br /> Public [)Other [ Delta Type of Casing 00, <br /> 15,rrrigation Approx. Eastern Specifications <br /> U Cathodic Protection Depth <br /> Depth of Grout Seal <br /> 17 Geophysical Type of Grout <br /> U Other Surface Seal Installed by PAN FCQ fi IZ. 4-loleV <br /> Repair Work Done [J Type of Pump _S U8 H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') — <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ (No septic tank or seepage pitpermitted ifpublic <br /> fsewe) iavailable within 200s <br /> Installation will serve: Residence — Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK F-1 Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. F-1 Type/Mfg Capacity <br /> SEWAGE SYSTEM � Distance to nearest: Well Foundation <br /> Property Line <br /> DESTRUCTION <br /> No. & Length of lines Total length/size <br /> LEACHING LINE LJ 9 Property Line <br /> FILTER BED Distance to nearest: Well Foundation <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS I_I <br /> 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 <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California." <br /> -contracting signature certifies the following: "I certify that in the performance of the work for which <br /> Contractor's hiring or sub <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applican st< All for 11 required inspections. Complete drawin on reye�rse side. te: <br /> Signed X Title: <br /> F R ARTMEN USE ONLY Stk 466-6781 <br /> Application Accepted by � `�i� -.� - Area <br /> Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> � <br /> Pit or Grout Inspection Date tdl/by 7� z <br /> Date Tracy 835-6385 <br /> Final Inspection by/ v <br /> Applicant - Return all copie to: Environment Health Permit/Services 1601 E. n Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> PERMIT N0. <br /> IINFO 3— <br /> 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br /> 6 <br />