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v V <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT /JJ <br /> 1601 ETelephoneNAVE(209)� 466-6780PERMIT NO. QQ <br /> ? <br /> 1N CA DATE ISSUED <br /> PERMIT EXPIRES 1 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 /> and the Ruleshis aRegulationsis made <br /> he San Joaquin Localwith <br /> Health San <br /> Joaquin.coCounty Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> des <br /> ribed <br /> (,pp [ nee-to N RoAo Subdivision Name Phone <br /> Job Address Address $23 '�.5g <br /> /)1ACNA/J6 a �y51y,$ Phone• <br /> Owner's Named« A e��l License No: <br /> Contractor's Name C <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP__ WORK: NEW WELL ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE __ I <br /> SEWER LINES �— PITS/SUMPS __ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHE0. WELL <br /> FOUNDATION <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well Excavation <br /> ❑Open Bottom ❑Manteca <br /> Industrial Dia. of Well Casing <br /> ❑ Domestic/Private ❑Gravel Pack ❑Tracy <br /> ❑ Public ❑Other ❑Delta Type of Casing <br /> IrrigationApprox. 13Eastern Specifications <br /> ❑Cathodic Protection <br /> Depth Depth of Grout Seal <br /> ❑Geophysical Type of Grout — <br /> Other Surface Seal Installed by -- <br /> Repair Work Done ❑ Type of Pump <br /> H p State Work Done ---- <br /> 09 <br /> Well Destruction ❑ Well Diameter SealinFilling Material (Below 5 <br /> (Below 50') �( <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION IBJ (No septic tank or seepage pit permitted if Public sewer is O <br /> available within 200 feet.) Q:h <br /> Installation will serve: Residence Commercialum — 2 <br /> ^C��� <br /> Number of living units: Number of bedrooms < Lot size p, <br /> Character of soil to a depth of 3 feet: Water table depthy <br /> Capacity No. Compartments <br /> SEPTIC TANK E] Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines O Total length/size <br /> FILTER BED ® Distance to nearest: Well D' Foundation /eI Property Line <br /> SEEPAGE PITS ❑ 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 <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 workman§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 applicy�� /�� �t calol for all r ired inspections. Complete drawing on reverse side. <br /> Signed X /VN'1 F Title: Date: ! U <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Area 1.3 ❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date §]c Manteca 823-7104 <br /> final Inspection by Date ? ❑ Tracy 835-6385 <br /> Applicant - Return all copie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> rEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />