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N FOR PERMIT <br /> 1? <br /> 190? t�) <br /> EALTH DISTRICT ' !' <br /> SAN JOAQUIN LOCAL H STAB 70N, CA V7 � <br /> 1601 E. HAZELTION AVE-, OEC 6 Igp- <br /> Telephone (209) 466-6781 7 <br /> ENVIROkrlE!�TAL HEALTH <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> FERMIT/SERV <br /> (Complete in Triplicate) <br /> described.This 1 190 <br /> uct and/or install the wort herein d ��. n is <br /> ealth District for a permit to construct Regulations of the San Joaquin <br /> 17 aquin Local H 11/pump and the Rules and <br /> Application is hereby made to the San 0 549 for sewage or No 1862 for we <br /> with San Joaquin county Ordinance No. <br /> made in compliance <br /> Local Health District, n City Lot Size PM <br /> pill 1:­ <br /> 0 <br /> Job Address hone <br /> z4 4t&RAO Address <br /> Owner's Name Phone <br /> 2 Icense No. <br /> " LY Address DESTRUCTION C3 <br /> contractor <br /> 0 DES <br /> C.—WW�\NEL­ REPLACEMENT OTHER <br /> F WELL/PUMP: SYSTEM REC3 <br /> TYPE PAIR 0 IS�O <br /> PUMP INSTALLATION 0 SEWER LINES --� D 1� SAL FLD.— PROP. LINE <br /> REST: SEPTIC TANK — PITS/SUMPS DISTANCE TO NEAREST: FOUNDATION --� AGRICULTURE WELL _ OTHER WELL <br /> SPECIFICATIONS TYPE OF WELL PROBLEM AREA Dia. of Well Casing <br /> INTENDED USE avation E <br /> Well xc <br /> 0 Open Bottom X Manteca Dia. of We <br /> . AUr Specifications <br /> 0 Industrial X Gravel Pack D .Tracy Type of Casing j2CL&e.1 Type of Grout <br /> ED Domestic/Private C3 Delta Depth of Grout Seal <br /> ,L CJ Public 0Other 0 Eastern Surface Seal Installed by <br /> _—Approx. Depth State Work Done <br /> irrigation, I � H.P. <br /> Repair Work Done 0 Type of Pump — <br /> 1 6 . I Seating Material (top <br /> Well Destruction 0 Well Diameter Filler Material (Below 501 <br /> Depth -11 DESTRUCTION 11 (No septic system permitted if public sewer is <br /> NEW INSTALLATION El REPAIR/ADDITION E3 DESTR available within 200 feet.) <br /> TYPE SEPTIC WORK: <br /> Residence Commercial— Other <br /> i installation will serve. N�mber of bedrooms Water table depth <br /> Number of living units: — 6 <br /> Character of soil to a depth of 3 feet: Capacity_-- No. Compartments <br /> SEPTIC TANK 0 Type/Mfg Method of Disposal -------- <br /> PKG. TREATMENT PLT. ❑ Well Foundation Property Line <br /> DiStance to nearest: <br /> I - Total length/size <br /> LEACHING LINE ❑ No. &!Length of lines Foundation— property Line <br /> I Well <br /> FILTER BED E3 Distance to nearest: <br /> Number <br /> EJ Depth Size--------------- Property Line <br /> SEEPAGE PITS Well Foundation <br /> SUMPS Distance to nearest: <br /> DISPOSAL PONDS 0 on and that the work will be done in accordance with San Joaquin county ordinances, state laws, a <br /> I hereby certify that I have prepared this applic8ti <br /> Local Health District. ing signat <br /> that in the performance of the work for which this permit is issued, I shall 1 <br /> rules and regulations of the San Joaquin r sub-contract <br /> s signature certifies the following: "I certify t <br /> Home owner or licensed agent' workman's compensation laws of California."Contractor's hieing o <br /> employ any Person in such manner as to become subject to workm s subject to workman's comPen <br /> certifies the following;"I certify that in the performance of the.work for which this permit is issued,I shall employ person <br /> tion laws of California." inspec 10 S. compie aw!Lg on, averse side. <br /> lic4nitir st call for a requi t, Date: <br /> The app <br /> Title: <br /> Signed <br /> R DEPARTMENTONLY US ONLY <br /> Area <br /> rea <br /> Application Accepted by <br /> Date Final inspection by <br /> Pit or Grout inspection by <br /> Additional Comments'. [I Manteca 823-7104 0 Tracy 635-6M <br /> P.O. Box 2o0g, Stk., CA 95201 <br /> 0 Stk i 466-Ml ❑0 Lodi 369-3621 1 E. Hazelton Ave., <br /> Applicant- Return all copies to: Environmental Health Permit/Services160 <br /> k� i I .CK RECEIVED By DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> CASH <br /> 4f, 14 <br /> INFO <br />