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i; <br /> APPLICATION I:GR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1501 E. HA7_EL T ON AVE . STC'."KTON, CA <br /> Telepho:le (209) 466-6781 <br /> PiRE5 7 YEF F7 FROM DATE ISSUED <br /> PERMIT EJ( ' <br /> '" k <br /> (Complete in TripVsAle) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made a compliance with San Joaquin County Loc ante No.50.9 for sewage or No.1V%2 far well; n+ <br /> ;pup and the Rules and Regulations of the San Joaq1 <br /> uin r`' <br /> Local Health <br /> District—City-- <br /> Lot Size 1?M <br /> Job Address .411 <br /> 7 Phune <br /> Owner's Name Tti5 Address —i.- <br /> Phone <br /> s License No. — <br /> Contractor's Name= WELL REPLACEMENT L3 DESTRUCTION <br /> TYPE OF WELLIPUMP: NEW WELL G OTHER Q <br /> PUMP INSTALLATION D SYSTEM NEPAIR G <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD._ PRO7. .INE <br /> OTHER WELL F' '• ^.Ll"n r$ <br /> FOUNDATION AGRICULTURE VJEL�t.�___ _ • - y ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Cas ng <br /> industrial u ❑Open Bo tom ❑ Manteca Dia. of Well Excavation- --- <br /> 13 T P of Casing___— Specifications <br /> � Domestic/Private G Gravel?ack !7 Tracy yP r Cri ''["� Type of Grout <br /> -- <br /> 0 Public u Other El Delta Depth of G*" Al F��+ <br /> {] Irrigation Apurox. Depth G Eastern Surface Seal Instailed by — - <br /> H.P._ S Work Don } <br /> � Repair 1A'ork Done Q TYpe of Pump //_ ataeti <br /> C <br /> ell Destruction Sk Well Diameter _j k, Sealing Material(top 50.1 - <br /> Dopth - Filler Material iBelow 501 ` 1' <br /> �. TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIRIADDITION L'. 0ESTRUCTtO111, id iJ availabJNo le withtic in 200 feet+tled+f public sewer is \ + <br /> Installation will serve: Residence— Commercial— ftther <br /> Number of!iving units: Number of bedrooms Water table depth_ <br /> Character of sol to a depth of 3 feex.__ Capacity No.Compartments <br /> SEPTIC TANK n Type/Mfg _.—_—� <br /> Method of Disposal <br /> PKG. TREATMENT PLT.0 Propeity Lino — 1 <br /> Distance to r-earesi: WPIC — Foundation— <br /> Total length/size <br /> LEACHING LINE No. &Length of lines Foundation Property Line— <br /> FILTER BED E: Distance to nearest: Well�. <br /> —�— Number <br /> SEEPAGE PITS C-. Depth -_Sire <br /> c Foundation ProPertY Line <br /> SUMPS it 61stance to nearest: +A ell <br /> DISPOSAL l <br /> I hereby certify tl.at I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, an <br /> rules and regulations of the San Joaquin Local Health District.g work for <br /> Home owner oshall rot <br /> rslicensed <br /> ne n such manner torb?come svo 0rhe ollo iVrkman'srtcomPthat <br /> nsatio"'aws of Cal;fo nia-e Contractor's lhiringl orsub•cont acunglsignaturre <br /> employ any Pe mi•-n this permit is issued,1 shall employ poison <br /> subject to workman's compensa- <br /> certifies the following:"I certify that In the performance of the work fo+ r P <br /> tion taws of Califorlia." <br /> The applicant mus call for all require inspe 'ion . Complete drawing on reverse side. <br /> Title: ��--- Date: __. - <br /> Signed <br /> pR DEPARTMENT USE ONLY <br /> Date� Area�.�� <br /> Application Accepted by Datey z� j <br /> Date Final Inspection by -- <br /> Pit or Grout inspection by t <br /> Additional Comments <br /> E7 Stk Lodi 369.3621 : Manteca 8217TG4 — _Tract/ B3rB35-6385 �— <br /> applicantt-- 57$1 Return al:copies to: Environmental Neal* Perrrlit;Service; 1501 E. Hazelton Ave., P.O. Bos 2009• Stk., CA 952.01 <br /> CK° T RECEIVED fay DATE FEitMiTNO, <br /> FEE AMDUN' DUE AMOUNT REMITTED CASH <br /> INFO <br /> 27 <br /> EN 17 24,n tv — <br /> EH �^S <br />