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PERMIT' NO. DATE <br />AMOUNT Our: AMOlAT REMITTED gAsf <br />• <br />RECEIVED RV <br />7 <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT P A v <br />1601 E. HAZELTON AVE., S1 OCKTON, CA :'; TNT <br />Telephone (209) 466-6781 li ED <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2 _____ ___ NOV <br />(Complete in Triplicate) <br />y 8 i <br />_weir) is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the if._ _ <br /> 'bed. This application is <br />in compliance with <br />San Joaquin County Ordinance No. 649 for sewage or No. 1862 for well/pump and the <br />Fr two <br />Health District. <br />CES <br /> <br />City Lot Size <br /> <br />` '-)---Li-e-e-----1(-14/-;;;P ‘,.. Phont 'Cr <br />. Addressi.,X* Vri..12?-7t <br /> <br /> <br />OTHER KExTettt 13/Ett, <br />PUMP :NSTALLATIOK3 SYSTEM REPAIR El <br />EA CONSTRUClION SPECIFICATIONS PROBLEM AR -t — C n <br />instaliation will serve: Reside. . ___ Commercial _____ Other <br />Number of living units: ._ Number of bedrooms .._._ <br />Coaracter of soil to a depth of 3 feet: <br />Water table depth <br />I'l'IC TANK r I Type/Mfg — Capacity No. Compartments <br />G. TREATMENT PIT. I 1 <br />Method of Disposal <br />Distance tr. r.larest: Well _— Foundation _____ Pmperty Line <br />:iACHING LINE il No. & Length of lines .......____---.—._ ._ Total length/size__ <br />11.11:11 GED 1 I Distance to nearest: Well —___ Foundation ______ _ Property Line — <br />- — ------------- ------------------ <br />EEGAGFi P115 I 1 Depth __Size — .._.. ._• Number _ <br />,t1k11P3 1 I Distance to nearest: Well ___..___ Fnundar:on ____.._____ Property Line _. <br />hernhy certify that I have prepared this application and that the work WII be dont- in accordance with San Joaquin county ordinances, state :aws, and lIFJ'OSAL PONDS ; I <br />tome owner or licensed agent's signature certifies the following. "I certify that in the performance of the work for which this permit is issued, I shall not ules and regulations of the San Joaquin local Health Diktric I. <br />implov any person in such manner as to become subject to workman's compensation laws 'if California." Contractor's hiring or sub-contract <br />lng signature <br />,:erti:ins the follow:ng: "I certify that in thc performance of the work for which this permit is ........ied, I shall employ persons subject to workman's compensa• <br />inn laws of California." <br />Eta, arpItcant must call for all required inspections. Complete drawing on r7 ...irse side. <br /> <br />ii----- ....- ...--,-• , . <br />... <br />Title, ....,:r V' ,;:_:,:i A-':: ._ )1.11, i.77.,e--r',. •-'''7'...,.,F r' , pat.,: <br />Signed I.-(,. <br />- • _,. <br />E ONLY "--"`"4// rl'( .r-- /It'. <br />Date 12--qL_ Area <br />Ai:Haines! Comments: _ <br />41=6 8781 ,7:1 Lodi 369-3621 El Manteca 823-7104 El Tracy 835-6395 <br />ir <br /> <br />-or Return all copies to: Environmental Health Permit/Services 1601 E. HAZOiton AVA., P.O. BOX 2099, Stk., CA 95201 <br />iikEilWai Joaquin <br />rar.tor <br />OF W LLIPLIMP: <br />NErne <br />l'ANCF TO NEAREST: SEPTiC TANK <br />NE WELL V WELL REP CEMENT DESTRUCTION ( I <br />SEWER LINES _AZ_A- _ DISPOSAL FLO...A.L.1— PROP. LINE /A <br />— <br />FOUNDATION qin? AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />(SP?! <br />INTENDED USE <br />n(iustrial <br />)nincsticfPrivate <br />)uhlic <br />o rg n atio <br />)air Wo.. none Ii <br />AI Destruction n ' Filler Materiai (Below 50) <br />PE OF SEPTIC WORK: NEW INSTALLATION I 1 fiErA111 /ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) <br />TYPE OF WEI_L <br />O Open Bottom <br />)10( Gravel: Pack <br />11 Othyr <br />d.i)Apptox. Depth <br />Type of Pump —_.— <br />Well Diameter <br />Depth _______—. <br />EManteca Dix. of Well Excavation _...,...._r_ Dia. of Well asi g <br />11 Tracy Type of Casing __Zit _..:4__-__— Specifications <br />fl Delta Depth of Grout Seal _Ie-,)LQ...!__—,._ Type of Grout re.iiitif ' <br />I I Eastern Slit face Seal In.:tailed by <br />H.P. _ State Work Done __—_ <br />Sealing Material (top 501 ---- <br />, <br />Aotuir.ario kccepted bY <br />Pit re Gout Inspection by_ — Date /14-C Final Inspection by Date <br />FOR DEPART