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�. -rZ _{_ - <br /> L HEALTH{ 1Ic7D1� / <br /> rl , tL TiiN AvE ' HT1 kTGN. _ cEP'"T NO <br /> _eleonone %091166-6 '.1 /3 <br /> ` /(��•�•5 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE '.SSUED <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 J <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address a Subdivision Name <br /> Owner's Name Lk, , , -z. r Phone <br /> r <br /> Contractor's Name A License No. Phone,V. x.20 <br /> TYPE OF WELL/PUMP WORK: NEW WELL F-1 WELL REPLACEMENT ❑ DESTRUCTION <br /> ` PUMP INSTALLATION SYSTEM REPAIR OTHER Lf <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> U Domestic/Private D Gravel Pack F-1 Tracy Dia. of Well Casing <br /> r. L—] Public f_1 Other Delta Type of Casing <br /> F, Irrigation Approx. Eastern <br /> Depth Specifications <br /> Cathodic Protection Depth of Grout Seal <br /> ❑Geophysical <br /> Other Type of Grout <br /> U <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L_� REPAIR/ADDITION LJ (No septic tank o seepage it permitted if public sewer is <br /> t-(�(� available within 200 feet.) <br /> Installation will serve: Residence Ix Commercial _ Other , ` �,�y3.J1, ^^^^^���--- <br /> Number of living units: �_ Number of bedrooms Lot size & ��[/tC� j. <br /> Character of soil to a depth of 3 feet: 'ev �,� Water table depth 4ff <br /> ` SEPTIC TANK Type/Mfg Capacity � ��_% <br /> L No. Compartments 2— <br /> PKG. <br /> PKG. TREATMENT PLT. <br /> Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: We11�G�/ Foundation �Q Property Line <br /> _ DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size Q <br /> FILTER BED Distance to nearest: Well Foundation _� Property Line <br /> SEEPAGE PITS Depth ✓—✓ Size 7J '" Number <br /> SUMPSDistance to nearest: Well MCI f Foundation �_ <br /> (,j f 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 /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> ` this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant st ll for all re wired in tions. Complete drawing verse side. <br /> Signed X_ �c/t� t .r Title: _p Date: <br /> �^ �, <br /> A NT US LY <br /> Application Accepted Area �� Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection Date (((��� Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies o: Environ ental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> o <br /> EH 13-24 REV. 10/82 10/82 500 <br /> �` 14-26 <br />