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-24 <br /> + APPLICATION FOR PERMIT <br /> • (a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '� <br /> 1601 E..HAZE;:TflN"�^A�VEC;STOCKT01�, CA <br /> Telephone (209) 46-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> w, {Complete in T(plicate) <br /> Application is hereby made to the San Joaquin Local Heatth District for a permit to construct and/or install the work herein described.This appiiication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or 862_ for well Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> � <br /> City ��TS — Lot Size — PM <br /> Job Address <br /> �0,� Address "-�ar'c-•yt�r.��-C�� - Phone 7 "Ort <br /> F <br /> Owner's Name {! <br /> s 6 z- <br /> I License No. Phone t <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 17 SYSTEM REPAIR ❑ OTHER J <br /> `-c` SEWER LINES DISPOSAL FLD.— PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PiTS/SUMPS — <br /> FOUNDATiON AGRICULTURE WELL _— OTHER WELL— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing _.. <br /> ❑ Industrial; i 0 Open Bottom. ❑ Manteca Dia.of Well Excavation r-4.-.-. <br /> T of Casing ,k -- i-,*•Specifications <br /> G Domestic%Private •.❑Gravel-Pack-,,\iQ Type - - . <br /> - -- .- -E-DeRa-•- - ••-Depth of Grout.Seal- _ TYPe of Grout— <br /> ❑ P blic' ❑'-Other•�,.�-.i..�- <br /> irrigation _Approx. Dep h �C Eastern Surface Seal Installed by e <br /> �/"- -L= � �' _ State Work Done <br /> Repair Work Done Type of Pump 1 H•P —_±�` <br /> Well Destruction ❑ Weil Diametar Sealing Matenal'itop <br /> Depth r i "4 F`i ler,Material iBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW IN?7,:ALLATION ❑L REPAIR/ADDITION 11 DESTRUCTION❑ (No septic system permitted if public sewer is <br /> :Jrb\ t available within 200 feet.) <br /> installation will serve: Residence . - Commercial, Other <br /> •� Number of living units: Number f bedrooms - <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/mfg,- Method of Disposal <br /> PKG.TREATMENT PLT.❑ /f <br /> Distance to nearest: W — Foundation Property Line <br /> LEACHING LINE ❑ No.&tzerigth of ii Total length/size <br /> t 11 <br /> FILTER BED ❑ Distance to nea t: Well _ ndation Property line <br /> SEEPAGE PITS C Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 ordinances,state laws,and <br /> 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 permit is issued,I dull not <br /> employ any person i manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the foflo ng:"i that in the Performance the work for which this pamtit is issued,1 shall employ persons subject to workman's compensa <br /> tion laws of ifomia." <br /> The aPpll t u ca oil roquir I rawing on revZ <br /> &n. <br /> Date: <br /> Sigma Title: U <br /> FOR DEPARTMENT USE ONLY 1 <br /> Data 44- , E Area 1 I <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection byDate <br /> Additional Commarrts:' <br /> ❑Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy ✓36-6385 <br /> Applicant-Return all copies to: Environmental Heafth Perrrdt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT"NO. t Q <br /> INFO CASH `y j . <br /> .en 13-24 cstEv.10/83i <br /> EH$4-26 i <br />