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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELiON AVE., STDCKTOACA '- <br /> Telephone (209) 466-6781 uPERMIT E XrIRES YEAR FROM DAT <br /> (Complete in Triplicate) SEP 2 7 1988 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the.vy r r' rWAs application is <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and 1� <br /> Local Health District. a San Joaquin <br /> t, <br /> Job Address �d <br /> City S Lot Size PM <br /> r-OW OR/GSC <br /> Owner's Name Address / <br /> ��Phone <br /> , IIContractor K s ddress TYPE OF WELL/PUMP: = License No. Phone <br /> NEW WELL ❑ WELLREPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONAD� /j^ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ONt,tRUCTION SPECIFICATIONS s <br /> ❑ Industrial � '^ T <br /> Cl Open Bottom �'�,p Manteca Dia>Gf-Well Excavation ' <br /> ❑ Domestic/Private "l5*Gravel Pack ❑Tracy Dia:of Well Casing <br /> i N Casing— Specifications <br /> I'1 Public LI Other "�� [1 Delta <br /> epfFi)of[jGrout Seal Type of Grout _ <br /> I I Irrigation � ,Approx. Depth I 1 Eastern ace Sea! Installed by <br /> Repair Work Done L3 Type of Pump H.P. j <br /> Well Destruction El Well Diameter State Work Done <br /> t Sealing Material (1p 501 <br /> Depth NFill6r Material (Below,50'),. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 AEPA)R.%ADb,ITI( I 1 DESTRUCTION I l (No septic system permitted Rt <br /> pubic sewer is r <br /> Installation will serve: Residence available within 200 feet lr , <br /> Commercial_ "Othgr �K <br /> Number of living units: - Number of bedrooms_L-}! <br /> Character of soil to a depth of 3 feet: <br /> i <br /> SEPTIC TANK :`" h 1 1/Vater table depth ; <br /> ❑ Type/Mfg " ` s�ari� 1 Cap city - v\ ..No. Compartments i�: <br /> PKG. TREATMENT PLT. © <br /> '. 1`Method of Disrposal <br /> Distance to nearest: Well <br /> Foundation Property-Line <br /> LEACHING LINE ❑ No. & Length of lines � ± Total length/size *\ <br /> FILTER SED ❑, Distance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sizei <br /> SUMPS L� .DistanNumberce to nearest: Well Foundationt i <br /> DISPOSAL PONDS p Property Line f <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 <br /> rules and regulations of the San Joaquin Local Health District. , 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 iA' ued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiung orub 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 a requir tions. Complete drawing on ev side, <br /> ll <br /> Signed X <br /> Date: <br /> /] FOR DEPARTMENT USE NLY <br /> Application Accepted by �} r I <br /> Date / CJ Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: Da e Ll k <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.D. Box 2009, Stk., C15201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ' <br /> INFO CASH RECEIVED 8Y DATE � ZPEIT'NO�.EH t3-241REV.F/7t 51 -EH 14-29 9 Lis - <br /> I�, 5 <br />