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APPLICATION FOR' PERMS <br /> SAN N LOCAL HEALTH <br /> � yR <br /> 1661 L. HA N _ � �N, CAf1AR PERMIT N0. ] <br /> - <br /> Telephone {209) 466678 <br /> rf <br /> �+ J0AQU4i4 LOCAL DATE ISSUEO v 1- <br /> PERMIT EXPIRES 1 YEAR FROM DATE LTM p3STRiCT <br /> r v 'v/ . ?(Complete in Triplicate)( A,z,)/J 205- !3�-l3 <br /> t' <br /> -� . _ <br /> 549 for sewage or No. 1862 for well/pump <br /> ,Application Thishereby <br /> plicationo�sthe <br /> madeninocompliaoncelw1th1San DJoaquin Count p0 permit <br /> to n r49 or se install the work herein <br /> described. P <br /> f the San Joaq, <br /> and the Rules and Regulations on Lo a1J division Name GA a <br /> Job AddressT Address 1 S U Phone <br /> ` Phone <br /> owner`s Name - <br /> Contractor's Name License No. <br /> p WELL REPLACEMENT DESTRUCTION U `G <br /> TYPE OF WELL/PUMP WORK: NEW WELL SYSTEM REPAIR OTHER LJ <br /> PUMP INSTALLATION K 1 <br /> DISTANCE TO NEAREST: DISPOSAL FLD. PROP. LINE <br /> SEWER L1NF5 SEPTIC TANK AGRICULTURE WELL �� OTHER WELL <br /> PITS/SUMPS <br /> LINE <br /> FOUNDATION <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TY?E OF WELL PROBLEM AREA pia. of Well Excavation O <br /> 0 en Bottom []Manteca <br /> Industrial U p pia. of Well Casing" <br /> 0 Domestic/Yriyate .Q Gravel Pack C Tracy <br /> 0 Public Other ❑Delta Type of Casing <br /> Approx. Eastern Specifications <br /> Irrigation Depth <br /> Cathodic Protection Depth of Grout Seal <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> H P � State Work Done ' �]�• <br /> Repair Work Done ❑ Type of Pump '- <br /> Sealing Material (top 50') <br /> Well Destruction ❑ Well Diameter � Filler Material (Below 50') <br /> Depth F <br /> REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U available within 200 feet.) <br /> Installation will serve: Residenceh Commercial Other <br /> Number of bedrooms Lot size _� <br /> Number'of living units: Water table depth <br /> Character of soil to a depth of 3 feet: Capacity f_ No. Compartments (\' <br /> SEPTIC TANK Type/Mfg Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/Mfg <br /> Foundation Property Line <br /> SEWAGE SYSTEM Distance to nearest: Well III <br /> N <br /> DESTRUCTIO �i <br /> 4 _ Total length/size <br /> No. & Length of lines <br /> LEACHING LINE [� Foundation _ Property Line <br /> FILTER BED Distance to nearest: Well <br /> � Number <br /> Size <br /> Depth <br /> SEEPAGE PITS „�J -0.- Property LineFoundation <br /> SUMPS E} Distance to nearest: ..Wehl <br /> . „� <br /> DISPOSAL PONDS D1 J ` <br /> ance <br /> I hereby certify that I have <br /> and rulepared this <br /> regulation <br /> the tion nSan hJoaquat in wLoc l Health District. foork will be done in drmanc ofhthe nwork gfor which uin ythis <br /> ordinances, state laws, <br /> erson in such manner as to become subject to workman compensation laws <br /> ofof the wCalifornia." <br /> f that in the per <br /> Home owner or licensed agent's signature certifies the following: 1 certify <br /> permit is issued, l shall not employ any p <br /> Contractor's hiring or sub-contracting ergonsusubjectwhich <br /> re ltoeworkmanoslcompensationrlaws oftify aCalifornithe a.° r <br /> this permit is issued;"I"shall emplo p <br /> The applican m st c 1 for r fired inspections. Completed wing on reverse side. Date <br /> Title: k PA J <br /> F Signed x 5tk 466-6781 <br /> 1Rf DEPART NT USE ONLY Area <br /> Application Accepted by Lodi 369-3621 <br /> 1 Additional Comments: Date _t Y Manteca 823-7104 pf �iL✓Y�►7 <br /> Pit or Grout Inspection by Tracy 835-6385 <br /> Date <br /> Final Inspection by <br /> 4 <br /> Applicant - Return all copies o vironmerital Health Permit/Services 1601 F. Hazel to Ave., P.O. Box 2009, Stk., CA 95201 <br /> ApP PERMIT NO. <br /> F DATE OE <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY l r. 43( - �� <br /> F I NFO ' � � <br /> ( 10182 500 <br /> EH 13-24 REV. 10/82 �ltvvr.. d �)Pt�k� _ G2ir-�4 V <br /> { 14-26 <br />