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TIQ <br /> APPLICATION FOR PERMIT I <br /> L HEALTH DIS <br /> SAN JOAO.UIN LOCA DISTRICT �Yy-- , <br /> 1601 E. HAZE i ON AVE., TON, CA� DEC 1 6 197 <br /> Telephone (209) 08 <br /> 1,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROME!I TAL HEALTH <br /> (Complete in Triplicate) FERMIT/SERVI ES <br /> pp' n is <br /> un Ordinance Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Laval Health District for a permit to construct and/or instep the work herein described. a <br /> made in compliance with San Joaquin Co ty <br /> Local Health District. PM <br /> .�. City Lot Size , <br /> Job Address a 7, [ / # <br /> =G Address 5�d �i. 0 hone <br /> jelti <br /> Owner's Name � <br /> Pe. i- � icense No. `'!6 l0 Phone <br /> lI�A .lLGIL. Address ° 1 DESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT ❑ <br /> i45W WELL OTHER ❑ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DIS, OSAL FLD. PROP. LINE <br /> SEWER LINES PITS/SUMPS.-� <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OT�iER WELL— <br /> FOUNDATION <br /> TYPE OF WELL PROBLAREp CONSTRUCTION SPE Dia of Well Casing <br /> INTENDED USE Manteca Dia. of Well Excavation <br /> l ❑ Industrial ❑ Open Bottom Specifications - 1 <br /> Gravel Pack ❑ Tracy r Type of Casing Type of Grout <br /> ❑ Domestic/Private Cl Delta Depth of Grout Seal Q <br /> l ❑ Public ❑ Other <br /> �Approx. depth C1 Eastern Surface Seal Installed by <br /> k Irrigation, State Work Done <br /> r r H.P. <br /> + Repair Work Done ❑ Type of Pump �— Sealing Material (top <br /> Well Destruction ❑ Well Diameter �� Filler Ma#erial {Below 50'! <br /> Depth f <br /> available within 200 feet.) (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAppITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is � <br /> i <br /> Installation will serve: Residence <br /> t Commercial— Other <br /> k <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: r Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg N Method of Disposal <br /> PKG. TREATMENT PLT. ❑ . Foundation Property Line -�- <br /> ` Diptance to nearest: Well <br /> i <br /> f - Total length/size <br /> i LEACHING LINE ❑ No. &Length of lines property Line <br /> r Foundation � <br /> ❑ Distance to nearest: Well <br /> FILTER BED <br /> 1Size Number <br /> SEEPAGE PITS ❑ Depth iProperty Line <br /> J. Foundaton�� <br /> SUMPS ' <br /> C] Distance to nearest: Well _. F <br /> DISPOSAL PONDS ❑ <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I rules and regulations of the San Joaquin Local Health District. i certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: " of arsons subject to workman's compensa <br /> employ any person in such manner as to�ome sucofohe work workman's <br /> compensation <br /> tion laws <br /> t is issued,f Sha I employ Contractor's hiring or sub contracting signature <br /> certifies the following."I certify that int performance <br /> r tion laws of California." <br /> The appli n st call for all repair inspectio s. Camille evil g on averse side. <br /> Date: <br /> k Title: <br /> Signed <br /> 2V R DEPARTMENT US ONLY / <br /> Date Area <br /> Application Accepted by pate <br /> Date /�Ir <br /> 1 1— Final inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: ❑ Manteca 823-2104 ❑Tracy 835-6385 <br /> ❑ Stk, 4664781 ❑ Lodi 369-3621 <br /> Applicant- Return all copies to: Environmental Health PerrnitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952 <br /> 01 <br /> m ti <br /> 9 f' CK RECEIVED SY DATE PERMIT N0. <br /> PEE AMOUNT DUE AMOUNT REMITTED CASKINFO <br /> t EH 13-241REV.I El 5) <br /> Eli 14-28 <br />