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APPLICATION FCZ PER 17! <br /> SAN Jo44UII, LOCAL H=-.LTH DISTRICT <br /> 1601 E. HAZELTON AVE_ STOCKTCN, CA PERE1lT NO. X 3—'7 $O <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES i 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. 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 A the San Joauip 'n Local Health District. <br /> Job Address\aoiDDfI-, 1�-p(�7�, Subdivision Name <br /> Owner's Name y�C' 'E►� � �Address 1in� Phone }-- <br /> Contractor's Name cense No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION L <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> i <br /> INTENDED JSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial U Open Bottom ❑Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br /> Public F-1 Other Delta <br /> Type of Casing <br /> Lj Irrigation Approx. Eastern v <br /> Specifications <br /> ❑Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> LJ Other <br /> Surface Seal Installed by <br /> Repair Work Done G Type of Pump H.P. State Work Done <br /> Well Destruction U Well-Diameter Sealing Material (top 501) <br /> u Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW:INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is r <br /> i available within 200 feet.) ; <br /> Installation will serve: Residence ! Commercial Other ... r <br /> Number of living units: y Number_of bedrooms Lot size ��Q <br /> Character of soil to a depth of 3•feet:. - �A IZ�P Water table depth ) <br /> SEPTIC TANK Type/Mfg ,� Ao.0 _ Capacity 2_0 d No, Compartments <br /> PKG. TREATMENT P)_T. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINEf' No. & Length of lines Total length/size �r�© <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size .33'� Number -3 ? <br /> SUMPS LI Distance to nearest: Well Foundation Property Line i <br /> DISPOSAL PONDS D <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 workmanIs 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 ap 'cant mu Fall equi d " spec tions. Complete wing on reverse side. <br /> Signed X �.� Title: Date <br /> FOR DEPAR <br /> Application Accepted b Area Q/ [ Stk 466-6781 <br /> Lodi 369-3621 <br /> Additional Comme r . <br /> e F Manteca 823-7104 <br /> Pit or Grout Inspe <br /> Final Inspection by A Date I7 Tracy 835-6385 <br /> Applicant - Return all copie to:. Environmental Health Permit/Services 1601 zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />