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APPLICA-ION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEA-',H OISTKICT �p a <br /> 1601 F. HA7ELTON AVE., STOCKION, CA PERMIT NO. D J <br /> Telephone (209; 466-6781 <br /> DATE ISSUED <br /> PERM EXPIRES 1 YEAR FROM-DATE ISS:IEC <br /> (Complete it Triplicate) <br /> Application is hereby rade to tre San Joaquin Local Health District °cr a permit to construct anal/or install Che work herein <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 •re San Joaquin/ ^al Health District. <br /> Job Address �.} ubdivision/1Nam11e <br /> Owner's Name (' =t:foP-hV6 Address , 2�1 �� hone M <br /> Contractor's Name License No. -- ��- Phcne <br /> ^x I <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT Q DESTRUCTION lJ" <br /> PUMP INSTALLATION SYSTEM REPAIR L] OTHER <br /> DISTANCE TO NEAREST: SEPTIC DANK SEWER IINFS CISPOSAL FLO. PROP. LINE ern <br /> FOUNDATION AGRICULTURE-WE-1-1 OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE CF WELL PROBLEM AREA CONSTRUCTION SP_ECIF'CATIOVS <br /> ❑ Industrial )Open Bottom FJ Manteca Dia.' of Well Excavation v <br /> U Domestic/Private EJ Gravel Pack E] Iracy Dia. of Well Casing <br /> LFI Public G Other ❑Delta <br /> _ � Type of Casing <br /> LV Irrigation Approx. Eastern <br /> Specifications <br /> E]Cathodic Protection Depth <br /> L,i6eophysical Depth of Grout Seal <br /> Grout <br /> Type <br /> LJ Other of <br /> ,Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. . State'Work Done <br /> Well' Destruction L? Well Diameter Sealing Material (top 501) .� <br /> 41(� <br /> Cepth =iller Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L!! REPAIR/ADDITION (No septic Lark or seepage pit permitted if public sewer is ' <br /> I available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Cher <br /> Number of living units: Number'of bedrooms Lot size <br /> Character of soil to a depth of 3 feet; Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments __ 1 <br /> PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE No. b Length of lines 0 Total length/sizes <br /> FILTER BED Distarce to nearest: WellU3 r7 Foundatiori4425�� Property Line <br /> SEEPAGE PITS [] Depth Size Number <br /> i <br /> SUMPS l_I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with-San Joaquir. 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: "1 certify that in the performance of the work for which this <br /> permit is issued, 1 shall not employ any person in such manner as Lo become subject to workrant 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 /> thispermit is ued, I shall emplo persons suoject to workman's compensation laws of California." <br /> The applic t4;4t call r 11 r it inspections. Complete drawi g on re erse side. n <br /> Signed Title: S.�+�'!_ r, -. Oated� ! i <br /> DEPARTMElrT SE ONLY <br /> Application Accepted'by Area 02— k tk 466-6781 <br /> Additional Comments: Lodi 369-3621 , <br /> Pit or Grout Inspection b Date _j Manteca 823-7104 <br /> Final Inspection by r ? jt• _ pate a 945 Tracy 835.5385 <br /> Applicant - Return all copies to: Environmental hea.Lh Pemit/Services 1601 E. Haze'ton Ave., P.O. Bax 2009, Stk., CA 95201 � <br /> FEE BASE AMOUNT DUE ( AMDJNT REMITTED R£CE;VED BY DA-E PERMIT NO. <br /> INFO <br /> to 17 3-SS <br /> EH 13-24 REV. 10/82 :0/82 SOC <br /> 14-.26 <br /> a <br />